Nurse Practitioner, Behavioral Health UM (PMHNP/Remote)

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.  * Must have active Florida NP license. 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., 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.
Job Qualifications REQUIRED QUALIFICATIONS:
  • 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 Registered Nurse and/or 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 to practice as a PMHNP, with the ability to obtain cross-state licensure as required.
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 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. Apply Now

Job Info

  • Job Identification2036333
  • Job CategoryClinical
  • Posting Date13/03/2026, 06:04
  • Job ScheduleFull time
  • Locations 200 Oceangate, Long Beach, CA, 90802, US
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