Director, Highly Integrated Dual Eligible Special Needs (hide - snp) Long - term Services And Supports (ltss)

Director, Highly Integrated Dual Eligible Special Needs (HIDE-SNP) Long-Term Services And Supports (LTSS)

The Director, Highly Integrated Dual Eligible Special Needs (HIDE-SNP) Long-Term Services and Supports (LTSS) is a senior leadership role responsible for the strategic and operational oversight of long-term services and supports across the organization. As an organizational subject matter expert for LTSS, the Director will lead the development, implementation, and evaluation of high quality, cost-effective healthcare outcomes for members within the dual-eligible population. This role ensures compliance with state and federal regulations and fosters cross-functional collaboration to support integrated care delivery for members receiving LTSS. It also ensures that LTSS operations align with the integration of Medicare and Medicaid benefits under Michigan's HIDE SNP model, meeting CMS and MDHHS expectations for person-centered, coordinated care. The LTSS Director works closely with the plan's Dual Special Needs Plans Director to ensure effective execution of LTSS coverage in coordination with external partners and reports directly to the Senior Director of Utilization Management.

Essential Functions

Strategic Leadership & Program Oversight:

• Develop and implement operational plans to improve LTSS access, utilization, and quality.
• Lead initiatives to align LTSS operations with contractual and regulatory requirements.
• Serve as the primary liaison for LTSS vendor relationships, including quality oversight and performance monitoring.
• Manage oversight of delegated entities or first tier, downstream, and related entities delivering LTSS functions, ensuring compliance with CMS and MDHHS requirements.
• Review delegate and vendor performance, including reports and corrective action plans, and monitor key performance trends related to LTSS delivery.
• Monitor LTSS performance across financial, clinical, and operational KPIs, ensuring integration of new regulatory requirements.

Clinical & Operational Integration:

• Collaborate with leaders across the enterprise (e.g., Medical Directors, Quality Improvement, Utilization Management, Care Management, Medicare Product Development, Claims, Digital Services, Population Health, Value Stream Leads) to ensure cohesive service delivery.
• Oversee utilization management for LTSS, including critical incident reporting and resolution.
• Support integration of LTSS service coordination systems (e.g., care management platforms, provider portals) with enterprise data systems.
• Lead implementation and oversight of LTSS elements of the CMS-approved Model of Care (MOC), including individualized care planning, risk stratification, interdisciplinary team (ICT) coordination, and timely HRAs.
• Align LTSS operations with the plan's Quality Improvement Program and Care Management framework to improve health outcomes.

Team Leadership & Development:

• Provide coaching and guidance to the LTSS team members. Lead onboarding, hiring, and training of new team members to support program growth. Foster a culture of accountability, continuous improvement, and member-centered care.
• Data-Driven Decision Making: Monitor and analyze LTSS data to identify trends and opportunities for improvement. Promote equitable access to LTSS by identifying and addressing disparities related to race, disability, language, geography, and social determinants of health (SDOH). Ensure services are accessible to individuals with disabilities, limited English proficiency, and those requiring culturally appropriate care. Ensure budget adherence and forecast staffing needs based on service volume and complexity.

Regulatory & Contractual Compliance:

• Develop and maintain LTSS policies and procedures in accordance with federal and state guidelines.
• Oversee the grievance process and ensure timely resolution of member issues.
• Ensure execution of HIDE SNP contract requirements, including MDHHS LTSS performance measures, person-centered planning, and timely reassessments.
• Lead readiness and response for state and CMS audits (e.g., MI Health Link, SNP MOC).
• Ensure continuity of care during provider or service transitions, per Medicare, Medicaid, and Michigan HIDE SNP contract.

Stakeholder Engagement:

• Engage with LTSS providers, community partners, and advocacy groups to enhance service coordination and satisfaction.
• Represent the organization in external audits and regulatory reviews.

Qualifications

• Required Bachelor's Degree in related field
• Preferred Master's Degree or other advanced degree in nursing, social work, health services research, health policy, information technology, or other relevant field.
• 7 years of relevant experience in related field Required
• 5 years of relevant experience in a leadership role with a demonstrated ability to lead teams and manage budgets. Required

Physical Demands

• Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
• Waist to Waist > 5 lbs: Seldom up to 10 lbs
• Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
• Waist to Overhead > 5 lbs: Seldom up to 10 lbs
• Bilateral Carry > 5 lbs: Seldom up to 10 lbs
• Unilateral Carry > 5 lbs: Seldom up to 10 lbs
• Pushing Force > 5 lbs: Seldom up to 10 lbs
• Pulling Force > 5 lbs: Seldom up to 10 lbs
• Sitting: Frequently
• Standing: Occasionally
• Walking: Occasionally
• Forward Bend - Standing: Seldom
• Forward Bend - Sitting: Occasionally
• Trunk Rotation - Standing: Seldom
• Trunk Rotation - Sitting: Occasionally
• Reach - Above Shoulder: Seldom
• Reach - at Shoulder or Below: Seldom
• Handling: Occasionally
• Forceful Grip > 5 lbs: Seldom
• Forceful Pinch > 2 lbs: Seldom
• Finger/Hand Dexterity: Frequently