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 :

PREFERRED QUALIFICATIONS :

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