Utilization Specialist (100% onsite)

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

Acadia Healthcare is a leading provider of behavioral healthcare services across the United States. Acadia operates a growing network of 250 plus behavioral healthcare facilities with approximately 11,100 beds in 39 states and Puerto Rico. With more than 23,000 employees serving approximately 75,000 patients daily, Acadia is the largest stand‑alone behavioral health company in the U.S.

Acadia Healthcare’s purpose is to Lead Care With Light and our mission is to be a world‑class organization that sets the standard for excellence in the treatment of mental health and addiction concerns. We strive to maintain our standing as a thought leader in the behavioral healthcare industry, providing treatment that is synonymous with compassion and innovation.

Tufts Medicine, a leading integrated academic health system in Massachusetts, and Acadia Healthcare, the largest standalone provider of behavioral health services in the U.S., have partnered to create the Tufts Medicine Behavioral Health Hospital, a state‑of‑the‑art, 144‑bed facility in Malden, Massachusetts. Slated to open in early 2026, this hospital is designed to address the growing need for high‑quality behavioral health services in the region.

The Utilization Specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility.

Essential Functions

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on utilization, non‑certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
• 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 or continued stay.
• Assist the admissions department with pre‑certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

Other Functions

• Perform other functions and tasks as assigned.

Education/Experience/Skill Requirements

• Required Education: High school diploma or equivalent.
• Preferred Education: Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
• Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred

Licenses/Designations/Certifications

• Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC‑I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de‑escalation and restraint certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility requirements.

Pay Range: $39.02 to $46.59/hr.

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

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