Director, Utilization Review

Job not on LinkedIn

🕒 June 19

🍁 Vermont – Remote

🍁 Vermont – Remote

💵 $135k - $155k / year

⏰ Full Time

🔴 Lead

👔 Director

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Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA)

WebsiteLinkedInAll Job Openings

51 - 200 employees

💼 Consulting

⚖️ Legal

🛡️ Insurance

Consulting • Legal • Insurance

Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA) is a full service Third Party Administrator (TPA) that specializes in the customization, marketing, and operation of self-funded employee benefit plans. With over 30 years of experience and a team of over 195 employees, CBG provides a wide array of products and services including self-funded medical and dental plans, Flexible Spending Accounts, Health Reimbursement Arrangements, and COBRA management. CBG aims to assist employers in building custom benefit plans while managing costs and ensuring compliance with regulations.

📋 Description

• Provide leadership and oversight of the Utilization Review department • Ensure consistent, evidence-based medical necessity determinations • Establish and enforce clinical guidelines, documentation standards, and review protocols • Maintain alignment with MCG guidelines and internal clinical governance standards • Ensure seamless alignment between UR and Claims workflows • Provide clinical expertise and documentation support for Appeals processes • Partner with Stop Loss teams on high-cost claim reviews and determinations • Promote end-to-end workflow efficiency across clinical and administrative functions • Ensure compliance with CMS, state, ERISA/non-ERISA, and accreditation requirements • Maintain audit-ready documentation and defensible clinical decisions • Oversee development and accuracy of denial and determination letters • Drive automation and digital workflow enhancements within UR • Enable interoperability across UR, Claims, Appeals, and vendor systems • Support real-time data exchange (EDI, integration platforms) • Leverage analytics to inform utilization trends, clinical outcomes, and population health initiatives • Establish quality assurance programs, audit processes, and performance standards • Develop and deliver training programs for clinical and operational staff • Implement dashboards and KPIs to measure productivity, compliance, and outcomes • Foster a culture of continuous improvement and accountability

🎯 Requirements

• Active Registered Nurse (RN) license • Minimum 5+ years of Utilization Review leadership experience • Strong knowledge of MCG guidelines, regulatory standards, and claims integration • Preferred experience within a TPA or health plan environment • Preferred familiarity with clinical platforms, workflow automation, and interoperability tools

🏖️ Benefits

• Medical, dental, and vision coverage with employer HSA contributions • Company-paid life, AD&D, and disability insurance • 401(k) with up to a 6% employer match • Generous paid time off, sick time, and 10+ paid holidays • Flexible Spending Accounts • A collaborative culture with regular company events