Nurse Practitioner, Behavioral Health UM (PMHNP)

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Job Description

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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.

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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.

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Job Qualifications

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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.

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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.

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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.