Nurse Practitioner, Behavioral Health UM (PMHNP)

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

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.

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 or UM 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., 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.