Job Summary:The Senior Director, LTSS Service Determinations provides enterprise leadership and strategic oversight for all LTSS Service Determination operations across CareSource's Medicaid, Dual Eligible, and LTSS markets. This role is accountable for the performance, compliance, quality, and operational effectiveness of Service Determination functions nationwide, with all Service Determination leaders and staff across LTSS markets reporting through this organization. The Senior Director establishes enterprise standards, policies, workflows, and performance expectations to ensure consistent, timely, and regulatory-compliant authorization and service determination decisions across all markets. In partnership with Clinical, Operations, Compliance, Quality, and Market Leadership, this role drives operational excellence, workforce planning, regulatory readiness, process transformation, and scalable growth strategies to support evolving business, member, and regulatory needs.Essential Functions:Enterprise SDT operational accountability across multiple LTSS markets.Oversight of all Service Determination Staff and Leaders.Standardization of policies, processes, and performance management of all SDT teams.Strategic planning and operational transformation responsibilities rather than day-to-day management of a single market.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 educationSix (6) years of experience in healthcare operations, with a strong focus on LTSS and Medicaid required Four (4) years of leadership experience managing teams in a healthcare or managed care environment required Four (4) years of experience with assessment tools (MDS, functional assessments, health risk assessments) preferred Four (4) 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 ServicesAbility to effectively identify business problems, assess proposed solutions, and understand the needs of business partners and stakeholdersAbility to communicate effectively with all levels of leadershipDevelops effective working relationships with business partners and stakeholdersStrong organizational, time management, analysis, and problem-solving skillsAbility to manage a project from start to finishStrong relationship building skills and leadership qualitiesTraining and teaching skills/change agentAbility to think critically and lead with strategyComprehensive knowledge base crossing all the following areas: Clinical Operations, Market Groups, Business Development, Network, and OperationsHands on proficiency in Microsoft Office tools, including Project, Outlook, Word, PowerPoint, and ExcelBusiness acumen and politically astute ability to act with diplomacy and sensitivity to cultural diversityLicensure 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:$162,600.00 - $284,700.00CareSource 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): SalaryOrganization Level Competencies Fostering a Collaborative Workplace CultureCultivate PartnershipsDevelop Self and OthersDrive ExecutionInfluence OthersPursue Personal ExcellenceUnderstand the BusinessAbout UsThe 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.
about 1 month ago