Behavioral Health Utilization Review Specialist

Pembroke Hospital; Pembroke (MA); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Competitive compensation

Generous PTO

Medical, dental, vision

401(k) with match

Student loan refinancing

Tuition discount

Student loan repayment

Tuition reimbursement

Career development

Job summary

Pembroke Hospital in Pembroke, MA, a 120-bed acute care and inpatient behavioral health facility south of Boston, seeks an Utilization Review Coordinator to join our patient-centered team.

You will perform daily clinical reviews across payer types to obtain authorization for continued treatment, educate the care team on payer expectations, and support documentation and appeals. This role supports compliant utilization and data-driven operations.

Qualifications

• Massachusetts licensure as an RN, LCSW, LICSW, or LMHC required.
• Experience in Utilization Management with a provider, insurer, or HMO.
• Experience in a behavioral health setting preferred.

Responsibilities

• Performs timely, daily clinical reviews with all payer types to secure authorization for continued treatment.
• Educates and guides on level of care requirements and payer expectations for patient acuity and utilization.
• Completes quality and timely appeal/denial letters; supports CMS audits and post-claim review.
• Collaborates with hospital operations to ensure documentation aligns with patient conditions.
• Contributes to monthly utilization data trends using hospital data tools for overall operations.
• Facilitates physician reviews with payers as required.
• Performs other duties as assigned by this position.

Skills

Utilization Management experience

Behavioral health experience

Education

Massachusetts licensure (RN, LCSW, LICSW, or LMHC)

Job description

Pembroke Hospital in Pembroke, MA, a 120-bed acute care and inpatient behavioral health facility south of Boston, seeks an Utilization Review Coordinator to join our patient-centered team.

You will perform daily clinical reviews across payer types to obtain authorization for continued treatment, educate the care team on payer expectations, and support documentation and appeals. This role supports compliant utilization and data-driven operations.