Nurse Practitioner, Behavioral Health UM (PMHNP/Remote) at Molina Healthcare
United States
<div style="font-style:normal;font-weight:400"> <strong>Job Description</strong> </div> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> <br><strong>Job Summary</strong> </div> <p>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.</p> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> * Must have active Florida NP license. </div> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> <strong>Job Duties</strong> </div> <ul> <li>Performs Behavioral Health utilization management reviews for inpatient, outpatient, and intermediate-level services using nationally recognized criteria (e.g., MCG, InterQual, ASAM).</li> <li>Reviews medical documentation to determine the medical necessity, level of care, and continued stay appropriateness for behavioral health services.</li> <li>Collaborates with Behavioral Health Medical Directors on complex or borderline cases, ensuring consistent application of criteria and alignment with regulatory standards.</li> <li>Identifies quality-of-care, safety, and compliance concerns and escalate to the Medical Director as appropriate.</li> <li>Maintains compliance with federal, state, and accreditation requirements (e.g., NCQA, URAC, CMS).</li> <li>Participates in UM quality audits, internal case reviews, and peer-to-peer education.</li> <li>Supports process improvement initiatives and contributes to the development of clinical review guidelines and training materials.</li> <li>Works under the medical direction and supervision of a licensed physician, consistent with state law and corporate policy.</li> <li>Obtains and maintains multi-state licensure to support national coverage needs.</li> <li>Participates in enterprise Behavioral Health workgroups, SAIs, and other cross-functional initiatives as assigned.</li> <li>Provides input to leadership regarding UM workflow optimization and emerging utilization trends.</li> </ul> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> </div> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> <strong>Job Qualifications</strong> </div> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> <strong>REQUIRED QUALIFICATIONS:</strong> </div> <ul> <li>Master’s degree in Psychiatric-Mental Health Nursing from an accredited program.</li> <li>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).</li> <li>Minimum 3 years of experience as a Registered Nurse and/or Nurse Practitioner, ideally in managed care, behavioral health, or utilization management.</li> <li>Demonstrated experience in the application of medical necessity criteria and regulatory guidelines.</li> <li>Active, unrestricted state license to practice as a PMHNP, with the ability to obtain cross-state licensure as required.</li> </ul> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> <strong>PREFERRED QUALIFICATIONS:</strong> </div> <ul> <li>Prior experience in a managed care organization or payer-based utilization management setting.</li> <li>Familiarity with Medicaid, Marketplace, and Medicare behavioral health regulations.</li> <li>Strong working knowledge of clinical criteria (e.g., ASAM, MCG, InterQual).</li> <li>Computer proficiency and experience with electronic medical record or UM systems.</li> <li> </li> </ul> <div style="font-style:normal;font-weight:400;margin-bottom:1em;margin-top:1em"> To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. <br> <br> Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. </div>
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