Nurse Practitioner, Behavioral Health UM (PMHNP)

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.

• 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 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.

• 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.,