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Nurse Practitioner, Behavioral Health UM (PMHNP)

Nurse Practitioner, Behavioral Health UM (PMHNP)

Molina HealthcareOkolona, Kentucky, US
21 hours ago
Job type
  • Full-time
Job description

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 :

  • 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 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.
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    Nurse Practitioner Behavioral Health • Okolona, Kentucky, US