Nurse Practitioner, Behavioral Health UM (PMHNP)

Job Description Job Summary Performs behavioral health utilization reviews, applying evidence-based criteria, and collaborating with physicians to ensure clinically appropriate, cost-effective, and regulatory-compliant care determinations. Assists in evaluating medical necessity, ensuring timeliness, and supporting the consistency of clinical decision-making across markets. Participates in a team-based, physician-led model that aligns with national clinical oversight standards and enterprise behavioral health initiatives. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties + Performs Behavioral Health utilization management reviews for inpatient, outpatient, and intermediate-level services using nationally recognized criteria (e.g., MCG, InterQual, ASAM). + Reviews medical documentation to determine the medical necessity, level of care, and continued stay appropriateness for behavioral health services. + Collaborates with Behavioral Health Medical Directors on complex or borderline cases, ensuring consistent application of criteria and alignment with regulatory standards. + Identifies quality-of-care, safety, and compliance concerns and escalate to the Medical Director as appropriate. + Maintains compliance with federal, state, and accreditation requirements (e.g., NCQA, URAC, CMS). + Participates in UM quality audits, internal case reviews, and peer-to-peer education. + Supports process improvement initiatives and contributes to the development of clinical review guidelines and training materials. + Works under the medical direction and supervision of a licensed physician, consistent with state law and corporate policy. + Obtains and maintains multi-state licensure to support national coverage needs. + Participates in enterprise Behavioral Health workgroups, SAIs, and other cross-functional initiatives as assigned. + Provides input to leadership regarding UM workflow optimization and emerging utilization trends. Job Qualifications REQUIRED QUALIFICATIONS: + Masteru2019s degree in Psychiatric-Mental Health Nursing from an accredited program. + Completion of a Psychiatric-Mental Health Nurse Practitioner program at the masteru2019s level with current national certification (PMHNP-BC) from the American Nurses Credentialing Center (ANCC). + Minimum 3 years of experience as a Registered Nurse and/or Nurse Practitioner, ideally in managed care, behavioral health, or utilization management. + Demonstrated experience in the application of medical necessity criteria and regulatory guidelines. + Active, unrestricted state license to practice as a PMHNP in KY, TX, FL, WA with the ability to obtain cross-state licensure as required. PREFERRED QUALIFICATIONS: + Prior experience in a managed care organization or payer-based utilization management setting. + Familiarity with Medicaid, Marketplace, and Medicare behavioral health regulations. + Strong working knowledge of clinical criteria (e.g., ASAM, MCG, InterQual). + Computer proficiency and experience with electronic medical record or UM systems. 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: $88,453 - $206,981 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-11-10