LTSS Service Care Manager

Job Title: LTSS Service Care Manager
Location: Remote California
Time Zone: Pacific Time (PST)
Duration: 4 Months
Schedule: Monday Friday, 8:00 AM 5:00 PM PST
Overtime: Possible

Pay Range: XXXXXXXXXXX - XXXXXXXXXXX Per hr on w2.

Position Overview

Education: Bachelor's Degree Required



Licensure: None Required

We are seeking an LTSS Service Care Manager to support a community transition initiative involving vulnerable long-term care members currently residing in Assisted Living Facilities (ALFs) .

Effective January 1, 2027, the Assisted Living Facility Transition Community Support service will be discontinued. This team will support members through transitions to appropriate alternative settings, including home, Skilled Nursing Facilities (SNF), Long-Term Care (LTC), Residential Care Facilities for the Elderly (RCFE), and Adult Residential Facilities (ARF) .

The Service Care Manager will assess member needs, coordinate transition activities, communicate with members, families, ALF providers, SNF/LTC providers, and community resources, and maintain accurate regulatory documentation. Team members will manage a caseload of 300+ members and will be supported by LTSS Social Workers and PHCO leadership.

This is a remote California-based position requiring strong communication, organization, documentation, case tracking, and care-transition skills.

Key Responsibilities Care Management & Transition Planning

• Evaluate member needs, available resources, and appropriate services to facilitate the best possible transition outcomes.
• Assist with developing and maintaining long-term care plans and service plans based on individual member needs.
• Coordinate transitions from ALF settings to appropriate alternative settings, including:
  • Home
  • SNF/LTC
  • RCFE
  • ARF
• Identify and coordinate appropriate providers, specialists, community resources, and support services.
• Monitor member status, care plans, service plans, and transition outcomes.
• Make recommendations based on changes in member needs and circumstances.
• Support vulnerable members throughout the transition process.

Member, Family & Provider Coordination

• Communicate directly with members and their families/caregivers regarding transition plans, services, benefits, and available resources.
• Contact ALF/ALW providers to follow up on member transitions and outstanding needs.
• Communicate with SNF/LTC providers regarding transition planning and member placement.
• Coordinate with healthcare providers and community partners to ensure identified services are accessible.
• Address questions, concerns, and issues related to member care and transition services.
• Provide education to members and families/caregivers regarding service options, healthcare benefits, referrals, provider instructions, and available resources.
• Maintain professional and effective communication with members, families, providers, and internal teams.

Case Tracking & Documentation

• Maintain accurate records of member interactions, transition activities, care plans, and outcomes.
• Document conversations and member/provider interactions in applicable systems.
• Track all assigned member transitions and ensure required activities are completed.
• Maintain regulatory and compliance documentation related to long-term care services.
• Collect, document, and maintain member information and care management activities in accordance with applicable state, federal, and third-party payer requirements.
• Ensure documentation is accurate, complete, timely, and compliant with established standards.

Resource & Community Support

• Provide resource support related to areas such as:
  • Housing
  • Independent living
  • Employment
  • Participant direction
  • Community services
  • Justice-related resources
  • Foster care/community support resources, as applicable
• Identify appropriate community resources based on member assessments and service plans.
• Facilitate access to services needed to support successful transitions and member stability.

Quality & Performance

• Track transition activities and outcomes against established performance metrics.
• Provide feedback to leadership regarding opportunities to improve quality of care and service delivery.
• Support cost-effective care coordination and appropriate utilization of community resources.
• Follow all applicable company policies, procedures, regulatory requirements, and quality standards.
• Perform other duties as assigned.

Typical Day

The role will primarily focus on member transition coordination and case tracking .

Typical activities include:

• Contacting ALWs/ALF providers to follow up on member transitions and outstanding needs.
• Communicating with SNF/LTC providers regarding transition arrangements.
• Speaking with members and their families regarding transition plans and available services.
• Reviewing member needs and available resources.
• Coordinating services and community resources.
• Documenting conversations and transition activities.
• Updating case tracking information and monitoring transition progress.
• Managing a caseload of 300+ members .

Performance Metric: The team will track completed and ongoing member transitions.

Required Qualifications

• Bachelor's Degree required.
• 3+ years of experience in one or more of the following:
  • Skilled Nursing Facility (SNF)
  • Assisted Living Facility (ALF)
  • Long-Term Care (LTC)
  • Social Work
  • Social Services
  • Care Management
  • Case Management
  • Care Coordination
• Experience with care transition planning .
• Experience with regulatory/compliance documentation .
• Experience with case tracking and documentation .
• Strong Microsoft Office skills.
• Ability to communicate confidently with members, families, healthcare providers, and facility personnel.
• Strong multitasking and organizational skills.
• Ability to manage a high-volume caseload.
• Strong documentation and data-management skills.
• Ability to work independently in a remote environment.

Preferred Qualifications

• Bachelor's degree in Social Work, Social Services, Human Services, Psychology, Sociology, Nursing, or another related field .
• Experience working with elderly, disabled, vulnerable, or medically complex populations.
• Experience with LTSS (Long-Term Services and Supports) .
• Experience with ALF, SNF, LTC, RCFE, ARF, or community-based care transitions.
• Previous healthcare case management or care coordination experience.
• Experience working with Medicaid or managed care populations.
• Experience coordinating services between members, families, providers, and community organizations.

Top 3 Must-Have Skills

1. Care Transition Planning
2. Regulatory/Clinical Documentation
3. Case Tracking & Data Management

Core Competencies

• Care coordination
• Case management
• Transition planning
• Member advocacy
• Provider communication
• Family/caregiver communication
• Documentation
• Case tracking
• Data management
• Multitasking
• Organization
• Time management
• Problem-solving
• Communication
• Attention to detail
• Ability to work independently
• Customer/member service

Work Environment

• 100% Remote
• Candidates must be located in California .
• Must be able to work Pacific Time hours.
• Monday Friday, 8:00 AM 5:00 PM PST.
• Occasional overtime may be required.
• This is not a field-based position .
• No regular in-person member or facility visits are required.
• No driver's license is required.
• No clinical license or certification is required.

Interview Process

• Interview conducted via Microsoft Teams .
• Cameras will be on during the interview.
• Manager candidate review is expected approximately 1 2 days after shortlisting .

Important Candidate Requirements

Candidates should be comfortable speaking directly with:

• Members
• Family members/caregivers
• ALF/ALW providers
• SNF/LTC providers
• Healthcare providers
• Internal care management teams