Manager, LTSS Service Determination Operations

Job Summary:

The Manager, LTSS Service Determination Operations is responsible for leading the day-to-day operations of a market specific LTSS service determination function, ensuring accurate, timely, and compliant translation of assessments into appropriate long-term services and supports (LTSS), ensuring decisions are member-centered, operationally executable, and aligned with regulatory and cost-of-care objectives.

Essential Functions:

• 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.

Education and Experience:

• 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
• Three (3) years of experience supporting process redesign, transformation, or system implementation preferred
• Experience with assessment tools (MDS, functional assessments, health risk assessments) preferred

Competencies, Knowledge and Skills:

• 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

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

Compensation Range:

$83,000.00 - $132,800.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. 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.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

 

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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Brand=Commonwealth Care Alliance