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Role Description

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.

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.

Requirements

• 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.

Benefits

Molina Healthcare offers a competitive benefits and compensation package.

Company Description

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.