Director, LTSS Service Determination Operations

📋 Description

• • Lead enterprise-level operations for Long-Term Services and Supports (LTSS) service determination across all markets, ensuring consistent application of strategy, operating standards, and performance expectations while allowing for market-level flexibility.
• • Direct and develop market-level Service Determination leaders through strategic guidance, performance oversight, and cross-market coordination to drive enterprise consistency, scalability, and sustainable program success.
• • Design, develop, and execute the LTSS service determination operating model including workflows, governance structures, performance frameworks, and future-state capabilities in partnership with Product, Clinical, Compliance, and Technology teams.
• • Ensure all service determinations are timely, accurate, and fully compliant with medical necessity guidelines, benefit rules, and regulatory requirements.
• • Drive standardization of service determinations across key LTSS categories including Personal Care Attendant (PCA), GAFC/AFC, Home Health, and Flexible Benefits.
• • Serve as the primary operational owner of the service determination workflow, both interim and future-state, overseeing end-to-end execution and continuous improvement.
• • Provide input into process design, rollout strategy, and system enhancements to ensure operational feasibility, scalability, and alignment with clinical and regulatory needs.
• • Identify gaps, inefficiencies, and variation in decision-making processes and implement standardized, data-informed solutions to improve quality and reduce errors.
• • Lead continuous improvement initiatives focused on enhancing quality of determinations, reducing turnaround time, and improving member experience.
• • Develop and execute comprehensive training and onboarding programs for new and existing staff to ensure readiness for evolving workflows, regulatory updates, and system changes.
• • Partner with Care Management, Clinical, and Compliance teams to ensure staff are proficient in medical necessity guidelines and distinctions between LTSS programs.
• • Recruit, develop, mentor, and lead key staff through coaching, performance management, and career development opportunities to drive high-quality outcomes.
• • Monitor and analyze key performance indicators to assess operational effectiveness and inform strategic adjustments.
• • Identify and mitigate operational risks related to service misalignment, duplication of services, and documentation gaps to ensure regulatory compliance and member safety.
• • Maintain hands-on proficiency in Microsoft Office tools including Project, Outlook, Word, PowerPoint, and Excel to support operational planning, reporting, and communication.
• • Demonstrate business acumen and political astuteness in navigating complex stakeholder environments with diplomacy and cultural sensitivity.
• • Apply critical thinking and strategic leadership to translate operational challenges into scalable solutions aligned with organizational and regulatory objectives.
• • Foster collaborative relationships with cross-functional teams including Product, Clinical, Compliance, and Technology to ensure seamless integration of service determination into broader care delivery systems.
• • Maintain comprehensive knowledge of Clinical Operations, Market Groups, Business Development, Network, and Operations to support enterprise-wide decision-making.
• • Perform additional job-related duties as assigned to support organizational goals and operational needs.