Nurse Practitioner, Behavioral Health UM (PMHNP)

Molina Healthcare; Tampa (FL); On-site; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare company in Florida is looking for a Behavioral Health Nurse Practitioner to perform utilization management reviews and collaborate with physicians to ensure effective care. Candidates should have a Master's in Psychiatric-Mental Health Nursing and at least 3 years of relevant experience. This full-time position offers a competitive pay range of $88,453 - $206,981 per hour.

Benefits

Competitive benefits and compensation package

Qualifications

• 3+ years of experience as a Registered Nurse and/or Nurse Practitioner in behavioral health.
• Active, unrestricted state license to practice as a PMHNP.
• Familiar with clinical criteria such as ASAM, MCG, InterQual.

Responsibilities

• Perform utilization management reviews for behavioral health services.
• Collaborate with Medical Directors on complex cases.
• Maintain compliance with regulatory standards.

Skills

Behavioral Health Utilization Management

Clinical Decision-Making

Medical Necessity Criteria

Collaboration with Physicians

Process Improvement

Education

Master’s degree in Psychiatric-Mental Health Nursing

Psychiatric-Mental Health Nurse Practitioner certification

Job description

Job 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.

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 escalates 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 in KY, TX, FL, WA 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.

Pay Range: $88,453 - $206,981 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.