Vacancy Description
Responsibilities
- Lead day-to-day operations for market-specific LTSS service determination functions to ensure accurate and compliant service translation.
- Serve as the primary operational lead and liaison for LTSS determinations, partnering with Clinical, Product, and Compliance stakeholders.
- 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.
- Own the service determination workflow, providing input into process design, rollout strategy, and system enhancements.
- Identify inefficiencies and implement standardized solutions to improve quality and turnaround time.
- Directly manage, coach, and develop a team of service determination professionals.
- Monitor key performance indicators and mitigate risks related to service misalignment or...
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