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: * 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 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 in SC to practice as a PMHNP, 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: $84,031 - $172,483.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.