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.
Job Duties
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Performs Behavioral Health utilization management reviews for inpatient, outpatient, and intermediate-level services using nationally recognized criteria (e.g., MCG, InterQual, ASAM).
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Reviews medical documentation to determine the medical necessity, level of care, and continued stay appropriateness for behavioral health services.
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Collaborates with Behavioral Health Medical Directors on complex or borderline cases, ensuring consistent application of criteria and alignment with regulatory standards.
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Identifies quality-of-care, safety, and compliance concerns and escalate to the Medical Director as appropriate.
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Maintains compliance with federal, state, and accreditation requirements (e.g., NCQA, URAC, CMS).
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Participates in UM quality audits, internal case reviews, and peer-to-peer education.
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Supports process improvement initiatives and contributes to the development of clinical review guidelines and training materials.
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Works under the medical direction and supervision of a licensed physician, consistent with state law and corporate policy.
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Obtains and maintains multi-state licensure to support national coverage needs.
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Participates in enterprise Behavioral Health workgroups, SAIs, and other cross-functional initiatives as assigned.
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Provides input to leadership regarding UM workflow optimization and emerging utilization trends.
Job Qualifications
REQUIRED QUALIFICATIONS:
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Master's degree in Psychiatric-Mental Health Nursing from an accredited program.
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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).
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Minimum 3 years of experience as a Nurse Practitioner, ideally in managed care, behavioral health, or utilization management.
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Demonstrated experience in the application of medical necessity criteria and regulatory guidelines.
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Active, unrestricted state license in SC to practice as a PMHNP, with the ability to obtain cross-state licensure as required.
PREFERRED QUALIFICATIONS:
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Prior experience in a managed care organization or payer-based utilization management setting.
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Familiarity with Medicaid, Marketplace, and Medicare behavioral health regulations.
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Strong working knowledge of clinical criteria (e.g., ASAM, MCG, InterQual).
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Computer proficiency and experience with electronic medical record or UM systems.
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: $79,607.9 - $172,483.79 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
