Nurse Practitioner, Behavioral Health UM (PMHNP) (WI)

Molina Healthcare•Long Beach, CA

About The Position

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.

Requirements

At least 5 years of experience as a registered nurse or nurse practitioner in managed care, behavioral health or utilization management, or equivalent combination of relevant education and experience.
Psychiatric-Mental Health Nurse Practitioner (PMHNP), and ability to obtain cross-state licensure as required. License must be active and unrestricted in state (WI) of practice.
Current national certification (PMHNP-BC) from the American Nurses Credentialing Center (ANCC).
Demonstrated experience in the application of medical necessity criteria and regulatory guidelines.
Strong customer service/member-centric focus.
Electronic Medical Record (EMR) proficiency.
Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
Strong time-management and prioritization skills, and 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 ability to work with diverse populations, various personalities and 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/applicable software program(s) proficiency.

Nice To Haves

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 (EMR) or utilization management systems.

Responsibilities

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., National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), Centers for Medicare and Medicaid Services (CMS)).
Participates in utilization management 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, scoreable action items (SAIs), and other cross-functional initiatives as assigned.
Provides input to leadership regarding utilization management workflow optimization and emerging utilization trends.