Manager, LTSS Service Determination Operations

CareSource; Mobile (AL); On-site; USD 75,000 - 120,000; Full time

Job summary

CareSource is seeking a Manager of LTSS Service Determination Operations to lead day-to-day market-specific LTSS determinations. You will ensure accurate, timely decisions, align with medical necessity guidelines and regulatory requirements, and drive cross-functional collaboration with CM, Clinical, Product, and Compliance teams.

The role requires a Bachelor's degree, 3 years in healthcare operations focused on LTSS/Medicaid, and 2 years of leadership experience in a healthcare environment.

Qualifications

• Bachelor's degree required.
• Three (3) years of experience in healthcare operations with LTSS/Medicaid.
• Two (2) years of leadership experience managing teams in healthcare/managed care.
• Three (3) years of experience supporting process redesign, transformation, or system implementation preferred.
• Experience with assessment tools (MDS, functional assessments, health risk assessments) preferred.

Responsibilities

• Lead LTSS service determinations for assigned markets and align with state rules, waivers, contracts, and workflows.
• Collaborate with Care Management, Clinical, Product, and Compliance stakeholders to ensure readiness and issue resolution.
• Ensure timely, accurate determinations in line with medical necessity, benefits, and regulatory requirements.
• Drive consistency of service determinations across PCA, GAFC/AFC, Home Health, and Flexible Benefits.
• Develop and own the service determination workflow; guide design, rollout, and system enhancements.
• Provide training and onboarding for staff; monitor readiness for updates and changes.
• Mentor and manage a team of service determination professionals; drive performance.
• Monitor KPIs and identify risks; implement standardized improvements.

Skills

Leadership

Healthcare operations

LTSS knowledge

Regulatory compliance

Project management

Communication

Analytical thinking

Education

Bachelor's degree

Tools

MDS tools

Assessment tools

Job description

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

Compensation Range

$74,700.00 - $119,520.00

Compensation

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=CareSource

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer‑centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.