Manager, LTSS Service Determination Operations

CareSource

Manager overseeing LTSS service determinations for CareSource ensuring operational readiness and compliance. Leading a team focused on quality outcomes and member-centered decision-making.

Posted 6/3/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $83,000 - $132,800 per yearWebsite

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

healthcare operationsLTSSMedicaidprocess redesigntransformationsystem implementationassessment toolsMDSfunctional assessmentshealth risk assessments

Soft Skills

leadershipcoachingmentorshipperformance managementissue resolutioncontinuous improvementtrainingteam managementcommunicationcollaboration

Certifications & Qualifications

Bachelor's degree

Industry Keywords

service determinationsmedical necessity guidelinesregulatory requirementsworkflowcontractual obligationsqualityturnaround timemember experiencekey performance indicatorsrisk mitigation

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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

Benefits

Comp & perks

substantial and comprehensive total rewards package