Nurse Practitioner, Behavioral Health UM (PMHNP)

Molina Healthcare seeks a Psychiatric-Mental Health Nurse Practitioner (PMHNP) to perform behavioral health utilization management reviews in a physician-led team model. In this role, you will apply evidence-based clinical criteria to evaluate medical necessity, level of care appropriateness, and continued stay determinations for inpatient, outpatient, and intermediate behavioral health services. You will work under physician medical direction to ensure clinically appropriate, cost-effective, and regulatory-compliant care determinations across multiple states.

Responsibilities

• Perform behavioral health utilization management reviews using nationally recognized criteria such as MCG, InterQual, and ASAM
• Review medical documentation to determine medical necessity, appropriate level of care, and continued stay appropriateness for behavioral health services
• Collaborate with behavioral health medical directors on complex or borderline cases to ensure consistent application of criteria and alignment with regulatory standards
• Identify quality of care, safety, and compliance concerns and escalate to the medical director as appropriate
• Maintain compliance with federal, state, and accreditation requirements including NCQA, URAC, and CMS standards
• Participate in utilization management quality audits, internal case reviews, and peer-to-peer education
• Support process improvement initiatives and contribute to development of clinical review guidelines and training materials
• Obtain and maintain multi-state licensure to support national coverage needs
• Participate in enterprise behavioral health workgroups and cross-functional initiatives as assigned
• Provide input to leadership regarding utilization management workflow optimization and emerging utilization trends

Required Qualifications

• At least 3 years of experience as a registered nurse or nurse practitioner in managed care, behavioral health, utilization management, or an equivalent combination of relevant education and experience
• Active, unrestricted Psychiatric-Mental Health Nurse Practitioner (PMHNP) license in state of practice with ability to obtain cross-state licensure as required
• Current national certification as PMHNP-BC from the American Nurses Credentialing Center (ANCC)
• Demonstrated experience in application of medical necessity criteria and regulatory guidelines
• Strong customer service and member-centric focus
• Electronic Medical Record (EMR) proficiency
• Responsive communication skills and ability to remain calm in high-pressure situations
• Strong time-management and prioritization skills with ability to focus on multiple projects simultaneously and adapt to change
• Problem-solving skills
• Ability to work within a variety of settings and adjust style as needed, including work with diverse populations and various personal situations
• Ability to work independently with minimal supervision and demonstrate self-motivation
• Ability to work cross-collaboratively within a highly matrixed organization
• Excellent verbal and written communication skills
• Microsoft Office suite and applicable software program proficiency

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 such as ASAM, MCG, and InterQual
• Computer proficiency and experience with electronic medical record (EMR) or utilization management systems

Clinical Setting

This position operates within a managed care organization's utilization management department, working under physician medical direction in a team-based model aligned with national clinical oversight standards.