Behavioral Health Utilization & Reimbursement Specialist

Tufts Medicine Behavioral Health Hospital; Malden (MA); On-site; USD 54,000 - 64,000; Full time

Job summary

Tufts Medicine Behavioral Health Hospital is seeking an Utilization Specialist to optimize reimbursement and care utilization in the new Malden, MA facility. This paid role emphasizes collaboration with managed care and clinical staff.

Responsibilities include reviewing plans, monitoring length of stay, and reporting utilization data. The position requires clinical experience and relevant licensure or supervision in a behavioral health setting.

Qualifications

• High school diploma or equivalent.
• Preferred: Associate's, Bachelor's, or Master's in Social Work, Behavioral or Mental Health, Nursing, or related field.
• Experience: Clinical experience required, or two+ years working with the facility's population; utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and the facility's clinical staff.
• Review insurance plans and coordinate communication on reimbursement requirements.
• Monitor patient length of stay and inform staff of impacts.
• Gather and report utilization data, discharges, and quality of services.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions.
• Assist admissions with pre-certifications of care.
• Provide ongoing staff training on documentation and medical necessity updates.

Skills

Clinical experience

Communication

Attention to detail

Interpersonal skills

Education

High school diploma or equivalent

Associate/Bachelor/Master in Social Work or related

Tools

EMR systems

Utilization software

Job description

Tufts Medicine Behavioral Health Hospital is seeking an Utilization Specialist to optimize reimbursement and care utilization in the new Malden, MA facility. This paid role emphasizes collaboration with managed care and clinical staff.

Responsibilities include reviewing plans, monitoring length of stay, and reporting utilization data. The position requires clinical experience and relevant licensure or supervision in a behavioral health setting.