Remote Utilization Review Rn Jobs in Sarasota, FL

JOB DESCRIPTION

Position Summary

The Program Director for the Home Health Coordinator Planning Office is responsible for leading (1) operational planning and coordination, (2) financial management, (3) regulatory communications and compliance, and (4) overall performance and execution of home health and private duty nursing (PDN) services for the Florida CMS population. This role serves as the central coordination point ('control tower') for complex operational issues, regulatory, provider engagement, member service fulfillment, cross-functional handoffs, and performance monitoring.

The Program Director will lead a multidisciplinary team of professionals and oversee the day-to-day operations of the Home Health Coordinator Planning Office. The role is accountable for identifying and removing barriers to service delivery, facilitating seamless transitions across departments, monitoring operational and financial performance, and driving timely resolution of member, provider, and regulatory issues. This position plays a critical role in ensuring compliance with Florida Medicaid contract requirements, regulatory reporting obligations, audit readiness activities, and state oversight expectations while maintaining strong operational controls. The role is also responsible for overseeing key financial indicators, monitoring service delivery costs, identifying financial risks and trends, and supporting data-driven decision-making to ensure services are delivered in a fiscally responsible manner.

The successful candidate will be highly analytical, detailed and action-oriented, and skilled at managing complex operational processes in a fast-paced healthcare environment. Success in this role requires the ability to simultaneously balance member outcomes, regulatory compliance, operational performance, provider network effectiveness, and financial accountability while driving execution across multiple business functions.

Key Responsibilities

• Lead and manage the Home Health Coordinator Planning Office.
• Serve as the operational 'quarterback' for home health and PDN fulfillment activities. 
• Interpret and implement regulatory requirements in coordination with key business functions. 
• Establish and oversee processes that ensure successful coordination between Clinical Operations, Care Management, Utilization Management, Claims, Network, Provider Services, and external providers.
• Drive execution of strategic and operational initiatives that support CMS contract requirements and organizational goals.
• Create operational discipline around issue tracking, escalation management, resolution, and accountability.

Cross-Functional Coordination & Handoff Management

• Bridge operational handoffs between internal departments and external stakeholders.
• Ensure seamless transitions of members requiring home health and PDN services.
• Facilitate coordination among health plan teams, providers, hospitals, nursing facilities, and community partners.
• Act as the escalation point for complex service, fulfillment, and operational issues.
• Issue Resolution & Barrier Removal

Regulatory Alignment and Compliance

• Maintain functional knowledge of regulatory requirements and environment.
• Interpret and provide consultative expertise on regulatory requirements to functional businessowners. 
• Work cross functionally to optimize regulatory implementations and performance.
• Lead compliant implementation, tracking and monitoring of regulatory requirements.

Remove operational roadblocks impacting member services and provider performance.

• Lead rapid-response efforts for unresolved fulfillment challenges, no-shows, staffing shortages, scheduling issues, and service interruptions.
• Coordinate corrective actions across multiple business units.
• Monitor resolution timelines and outcomes to ensure member-centered service delivery.

Analytics, Reporting & Financial Performance

• Leverage data to identify trends, risks, service gaps, and improvement opportunities.
• Partner with analytics teams to develop reporting and dashboards supporting operational oversight.
• Monitor utilization, fulfillment, quality, provider performance, encounter activity, and financial metrics.
• Analyze operational and financial impacts of performance trends and recommend corrective actions.
• Support executive reporting and strategic decision-making through meaningful business insights.

Provider Engagement & Performance Oversight

• Partner closely with home health agencies, PDN providers, and network leadership.
• Monitor provider performance, capacity, scheduling effectiveness, fulfillment rates, and operational readiness.
• Support provider issue resolution and service recovery activities.
• Facilitate ongoing collaboration and communication with provider organizations.

Program Governance & Continuous Improvement

• Establish governance processes, performance reviews, and operational monitoring routines.
• Lead root-cause analysis efforts and implement sustainable solutions.
• Develop standard operating procedures, workflows, and escalation pathways.
• Drive continuous improvement initiatives focused on quality, efficiency, and member experience.

Required Qualifications

Education

• Bachelor's degree - Healthcare Administration, Business Administration, Public Health, Operations Management, Finance, Data Analytics, or related field.
• Master's degree preferred, not required.

Experience

• 7+ years of progressive healthcare operations, managed care, program management, or healthcare services leadership experience.
• 3+ years of direct leadership experience managing teams and operational programs.
• Experience working in Medicaid, managed care, care management, home health, PDN, provider operations, or healthcare service delivery environments preferred.
• Proven success managing complex cross-functional initiatives and operational transformation efforts.

Knowledge, Skills & Abilities

• Leadership & Execution
• Strong ability to drive accountability and produce results in a highly matrixed environment.
• Demonstrated success leading teams through ambiguity and change.
• Exceptional organizational and project management skills.
• Advanced analytical and problem-solving capabilities.
• Ability to interpret, communicate, and implement complex regulatory requirements. 

Operational Excellence

• Detail-oriented with a focus on execution and follow-through.
• Ability to identify risks early and proactively implement mitigation strategies.
• Strong process improvement and operational design capabilities.

Data & Analytics

• Ability to collate and interpret complex operational and financial data.
• Proficiency with dashboards, KPIs, reporting, and performance measurement.

Financial Acumen

• Understanding of healthcare operational economics and financial performance drivers.
• Ability to evaluate operational decisions through a financial lens.
• Experience assessing cost, utilization, productivity, and performance impacts.

Communication & Collaboration

• Exceptional written and verbal communication skills.
• Strong executive presence and ability to engage senior leadership.
• Skilled facilitator capable of aligning diverse stakeholders around solutions.

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To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $80,412 - $156,803.45 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.