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.
Company Overview
CareSource provides managed care services to Medicaid beneficiaries. It was founded in 1989, and is headquartered in Dayton, Ohio, USA, with a workforce of 1001-5000 employees. Its website is https://www.caresource.com/.