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.

Essential Job Duties

• Performs behavioral health utilization management reviews for inpatient,

• Reviews medical documentation to determine the medical necessity, level of

• Collaborates with behavioral health medical directors on complex or borderline

• Identifies quality of care, safety, and compliance concerns and escalate to

• Maintains compliance with federal, state, and accreditation requirements

• Participates in utilization management quality audits, internal case reviews,

• Supports process improvement initiatives and contributes to the development of

• Works under the medical direction and supervision of a licensed physician,

• Obtains and maintains multi-state licensure to support national coverage

• Participates in enterprise behavioral health workgroups, scoreable action

• Provides input to leadership regarding utilization management workflow

• At least 3 years of experience as a registered nurse or nurse practitioner in

• Psychiatric-Mental Health Nurse Practitioner (PMHNP), and ability to obtain

• Current national certification (PMHNP-BC) from the American Nurses

• Demonstrated experience in the application of medical necessity criteria and

• Strong customer service/member-centric focus.

• Electronic Medical Record (EMR) proficiency.

• Responsive in all forms of communication, and ability to remain calm in

• Strong time-management and prioritization skills, and ability to focus on

• Problem-solving skills.

• Ability to work within a variety of settings and adjust style as needed,

• Ability to work independently, with minimal supervision and demonstrate

• Ability to work cross-collaboratively within a highly matrixed organization.

• Excellent verbal and written communication skills.

• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Prior experience in a managed care organization or payer-based utilization

• Familiarity with Medicaid, Marketplace, and Medicare behavioral health

• Strong working knowledge of clinical criteria (e. g., ASAM, MCG, InterQual).

• Computer proficiency and experience with electronic medical record (EMR) or

Molina Healthcare offers a competitive benefits and compensation package. Molina
Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.