Director, LTSS Service Determination Operations

Job Summary:

The Director, LTSS Service Determination Operations is responsible for leading the enterprise level operations of the LTSS service determination function, ensuring accurate, timely, and compliant translation of assessments into appropriate long-term services and supports (LTSS), and partnering closely with Care Management, Product, & Utilization Management teams to ensure decisions are member-centered, operationally executable, and aligned with regulatory and cost-of-care objectives.

Essential Functions:Provide enterprise‑level leadership and oversight of LTSS service determination operations across all markets, ensuring consistent application of strategy, operating standards, and performance expectations while enabling appropriate market‑level flexibility.

Direct and develop market‑level Service Determination leaders, providing strategic guidance, performance oversight, and cross‑market coordination to drive enterprise consistency, scalability, and sustainable program success.

Lead the development and execution of the LTSS service determination operating model, including enterprise workflows, governance, performance frameworks, and future‑state capabilities, in partnership with Product, Clinical, Compliance, and Technology leaders.

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.

Recruits, develops, and leads key staff.

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

Master's degree preferred
Equivalent years of relevant work experience may be accepted in lieu of required education
Five (5) years of experience in healthcare operations, with a strong focus on LTSS and Medicaid required

Three (3) years of leadership experience managing teams in a healthcare or managed care environment required

Three (3) years of experience with assessment tools (MDS, functional assessments, health risk assessments) preferred

Three (3) years of experience supporting process redesign, transformation, or system implementation preferred
Competencies, Knowledge and Skills:Deep understanding of LTSS programs, including PCA (Personal Care Attendant), GAFC/AFC, Home Health Services, and Home and Community Based Services

Ability to effectively identify business problems, assess proposed solutions, and understand the needs of business partners and stakeholders

Ability to communicate effectively with all levels of leadership

Develops effective working relationships with business partners and stakeholders

Strong organizational, time management, analysis, and problem-solving skills

Ability to manage a project from start to finish

Strong relationship building skills and leadership qualities

Training and teaching skills/change agent

Ability to think critically and lead with strategy

Comprehensive knowledge base crossing all the following areas: Clinical Operations, Market Groups, Business Development, Network, and Operations

Hands on proficiency in Microsoft Office tools, including Project, Outlook, Word, PowerPoint, and Excel

Business acumen and politically astute ability to act with diplomacy and sensitivity to cultural diversity
Licensure and Certification: None
Working Conditions:General office environment; may be required to sit or stand for extended periods of time
Ability to travel as required by the needs of the business.

Compensation Range:
$135,600.00 - $237,400.00CareSource 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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