Manager, LTSS Service Determination Operations

📋 Description

• • Lead day-to-day operations of LTSS service determination functions within assigned market(s), ensuring alignment with state-specific program rules, waiver requirements, and contractual obligations.
• • Serve as the primary market-level liaison for LTSS service determinations, partnering with Care Management, Clinical, Product, and Compliance stakeholders to ensure operational readiness and timely issue resolution.
• • Ensure accurate and timely translation of member assessments into appropriate long-term services and supports (LTSS), adhering to medical necessity guidelines, benefit rules, and regulatory requirements.
• • Drive consistency in service determinations across PCA (Personal Care Attendant), GAFC/AFC, Home Health, and Flexible Benefits programs.
• • Own the end-to-end service determination workflow, including interim and future-state process design and implementation.
• • Provide input into process redesign, system enhancements, and rollout strategies to ensure operational feasibility, scalability, and compliance.
• • Identify gaps, inefficiencies, and variations in decision-making processes and implement standardized, scalable solutions.
• • Lead continuous improvement initiatives focused on enhancing quality, reducing turnaround time, and improving member experience.
• • Develop, deliver, and execute training and onboarding programs for new and existing service determination team members.
• • Ensure team readiness for new workflows, regulatory updates, and system changes through coordinated preparation and communication.
• • Collaborate with Care Management, Clinical, and Compliance teams to ensure staff are trained on medical necessity guidelines and distinctions between LTSS programs.
• • Directly manage, coach, and develop a team of service determination professionals, providing performance feedback and mentorship.
• • Monitor key performance indicators to evaluate team effectiveness and drive accountability.
• • Identify and mitigate operational risks related to service misalignment, duplication of services, and documentation deficiencies.
• • Maintain proficiency in Microsoft Office applications including Word, Excel, and PowerPoint to support reporting, analysis, and communication.
• • Demonstrate strong written and verbal communication skills to effectively engage cross-functional teams and stakeholders.
• • Apply critical thinking and problem-solving skills to resolve complex operational challenges while maintaining attention to detail.
• • Work independently and collaboratively within a remote environment to achieve operational goals and team objectives.
• • Uphold high levels of professionalism and build strong working relationships across departments and levels of the organization.
• • Prioritize and accomplish goals in a fast-paced, regulated healthcare environment with evolving requirements.
• • Perform additional job-related duties as assigned to support organizational needs.