Remote Utilization Review Rn Jobs in Spring Hill, FL

JOB DESCRIPTION Job Summary

Provides subject matter expertise and leadership to healthcare services function - providing support for project/program/process design, execution, evaluation and support, and ensuring compliance with regulatory and internal standards, practices, policies and contractual commitments. Contributes to overarching strategy to provide quality and cost-effective member care. 
 

The Program  Manager plans and executes internal HCS projects and programs involving department or cross-functional teams of subject matter experts, delivering products from the design process to completion in collaboration with others. Manages programs providing ongoing communication of goals, evaluation, and support to ensure compliance with standardized protocols and processes. May engage and oversee the work of external vendors. Focuses on process improvement, organizational change management, program management, and other processes relative to the business. Serves as a subject matter expert and leads programs to meet critical needs. 
Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements. Collaborates with operational leaders within the business to provide recommendations for process improvement opportunities. Conducts quality audits to assess Molina HCS staff educational needs and service quality and implement quality initiatives as appropriate. Creates business requirement documents, test plans, requirements traceability matrix, user training materials, and other related documentation.
 

Essential Job Duties

Collaboratively plans and executes internal healthcare services projects and programs involving department or cross-functional teams of subject matter experts - delivering products from the design process to completion. 
Provides ongoing communication related to program goals, evaluation and support to ensure compliance with standardized protocols and processes.

May engage and oversee the work of external vendors.

Focuses on process improvement, organizational change management, program management and other processes relative to business needs.

Serves as a subject matter expert and leads healthcare services programs to meet critical needs.

Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements. 
Conducts quality audits to assess healthcare services staff educational needs and service quality, and implements quality initiatives within the department as appropriate.

Creates business requirements documents (BRDs), test plans, requirements traceability matrix (RTMs), user training materials and other related business documents. 

Required Qualifications

At least 5 years of health care experience, including experience in clinical operations, and at least 3 or more years in one or more of the following areas: utilization management, care management, care transitions, behavioral health, or equivalent combination of relevant education and experience. 
Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Advanced Practice Social Worker (APSW), Certified Health Education Specialist (CHES), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC) or Licensed Marriage and Family Therapist (LMFT). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. 
Strong analytical and problem-solving skills.
Strong organizational and time-management skills.
Ability to work in a cross-functional, professional environment.
Experience working within applicable state, federal, and third-party regulations.
Strong verbal and written communication skills. 
Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases.
Preferred Qualifications

Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care or management certification. 
Leadership experience. 
Medicaid/Medicare population experience. 
PMP preferred
Pediatric experience preferred
Experience with Florida Medicaid
#PJHS

#LI-AC1

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $73,102 - $142,549 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.