[Remote] Manager, LTSS Service Determination Operations

Note: The job is a remote job and is open to candidates in USA. CareSource is a healthcare organization focused on delivering quality services to its members. The Manager, LTSS Service Determination Operations is responsible for leading operations related to long-term services and supports, ensuring compliance and member-centered decisions while collaborating with various stakeholders.

Responsibilities

• Serve as the primary operational lead for LTSS service determinations within an assigned market(s), ensuring alignment with state‑specific program rules, waiver requirements, contractual obligations, and workflow nuances
• Act as the key market‑level liaison for LTSS service determinations, partnering with local Care Management, Clinical, Product, and Compliance stakeholders to ensure operational readiness and issue resolution
• Ensure timely and accurate determinations in alignment with medical necessity guidelines, benefit rules, and regulatory requirements
• Drive consistency in service determinations across PCA, GAFC/AFC, Home Health, and Flexible Benefits
• Serve as the primary operational owner of the service determination workflow (interim and future-state)
• Provide input into process design, rollout strategy, and system enhancements, ensuring operational feasibility and scalability
• Identify gaps, inefficiencies, and variation in decision-making and implement standardized solutions
• Lead continuous improvement initiatives focused on quality, turnaround time, and member experience
• Develop and execute training and onboarding programs for new and existing staff
• Ensure team readiness for new workflows, regulatory updates, and system changes
• Partner with CM, Clinical and Compliance teams to ensure staff are trained on medical necessity guidelines and LTSS program distinctions
• Directly manage and develop a team of service determination professionals
• Provide coaching, mentorship, and performance management to drive high-quality outcomes
• Monitor key performance indicators
• Identify and mitigate risks related to service misalignment, duplication of services, and documentation gaps
• Perform any other job related duties as requested

Skills

• Bachelor's degree required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Three (3) years of experience in healthcare operations, with a strong focus on LTSS and Medicaid required
• Two (2) years of leadership experience managing teams in a healthcare or managed care environment required
• Understanding of LTSS programs, including PCA (Personal Care Attendant), GAFC/AFC, Home Health Services, and Home and Community Based Services
• Proficient with Microsoft Office to include Word, Excel, and PowerPoint
• Excellent written and verbal communications skills
• Ability to develop, prioritize and accomplish goals
• Detail oriented
• Strong interpersonal skills and high level of professionalism
• Effective listening and critical thinking skills
• Effective problem-solving skills with attention to detail
• Ability to work independently and within a team
• Strong negotiation skills
• Excellent leadership skills
• Ability to create and maintain excellent working relationships
• Three (3) years of experience supporting process redesign, transformation, or system implementation preferred
• Experience with assessment tools (MDS, functional assessments, health risk assessments) preferred

Benefits

• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

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