Senior Director, LTSS Service Determinations

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 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 (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 Services
• Ability to effectively identify business problems, assess proposed solutions, and understand the needs of business partners and stakeholders
• Ability to communicate effectively with all levels of leadership
• Develops effective working relationships with business partners and stakeholders
• Strong organizational, time management, analysis, and problem-solving skills
• Ability to manage a project from start to finish
• Strong relationship building skills and leadership qualities
• Training and teaching skills/change agent
• Ability to think critically and lead with strategy
• Comprehensive knowledge base crossing all the following areas:  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

Licensure 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 - $284,700.00 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

Salary

Competencies

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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