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.
Essential 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., 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.
Required Qualifications
-
At least 3 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 (FL) must be active and unrestricted in state 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.
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 (EMR) or utilization management 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.
