Director, Utilization Review

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🔥 0 minutes ago

🍁 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

Who We Are:

📋 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