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.

• 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.

• 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 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 in SC to practice as a PMHNP, with the ability to obtain cross-state licensure as required.

• 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.