Nurse Practitioner, Behavioral Health UM (PMHNP)

Job

Description

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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.

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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.

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Job

Qualifications

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REQUIRED

QUALIFICATIONS :

Master’s degree in Psychiatric-Mental Health

Nursing from an accredited program.

Completion of a Psychiatric-Mental Health

Nurse Practitioner program at the master’s 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, with the ability

to obtain cross-state licensure as

required.

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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.