Senior Director, LTSS Service Determinations

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $162.6k - $284.7k / year

⏰ Full Time

🟠 Senior

👔 Director

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Provide enterprise leadership and strategic oversight for LTSS Service Determination operations across Medicaid, Dual Eligible, and LTSS markets • Own performance, compliance, quality, and operational effectiveness of Service Determination functions nationwide • Establish enterprise standards, policies, workflows, and performance expectations for authorization and service determination decisions • Direct and develop market-level Service Determination leaders and coordinate across markets • Lead development and execution of the LTSS service determination operating model, governance, performance frameworks, and future-state capabilities • Ensure timely and accurate determinations aligned with medical necessity guidelines, benefit rules, and regulatory requirements • Drive consistency across PCA, GAFC/AFC, Home Health, and Flexible Benefits determinations • Own interim and future-state service determination workflows • Provide input into process design, rollout strategy, and system enhancements • Identify gaps and inefficiencies and implement standardized solutions • Lead continuous improvement initiatives focused on quality, turnaround time, and member experience • Develop and execute training and onboarding programs • Ensure readiness for new workflows, regulatory updates, and system changes • Partner with CM, Clinical, and Compliance teams on training and program distinctions • Recruit, develop, coach, mentor, and manage performance of key staff • Monitor key performance indicators and mitigate service misalignment, duplication, and documentation risks • Perform other job-related duties as requested

🎯 Requirements

• Bachelor's degree required • Master's degree preferred • Equivalent years of relevant work experience may be accepted in lieu of required education • Six (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, including MDS, functional assessments, and health risk assessments, preferred • Four (4) years of experience supporting process redesign, transformation, or system implementation, preferred • Deep understanding of LTSS programs, including PCA, GAFC/AFC, Home Health Services, and Home and Community Based Services • Ability to identify business problems, assess proposed solutions, and understand stakeholder needs • Ability to communicate effectively with all levels of leadership • Strong organizational, time management, analysis, and problem-solving skills • Ability to manage projects from start to finish • Strong relationship-building skills and leadership qualities • Training and teaching skills/change agent capability • Ability to think critically and lead strategically • Comprehensive knowledge across Clinical Operations, Market Groups, Business Development, Network, and Operations • Hands-on proficiency in Microsoft Office tools, including Project, Outlook, Word, PowerPoint, and Excel • Business acumen and politically astute ability to act with diplomacy and sensitivity to cultural diversity • Ability to travel as required by business needs • No licensure or certification required

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Employee total well-being support • Equal Opportunity Employer environment fostering belonging and supporting individuals of all backgrounds