Healthcare Utilization Review Specialist

Job not on LinkedIn

🔥 1 minute ago

🗻 New Hampshire, Vermont – Remote

🗻 New Hampshire – Remote 🍁 Vermont – Remote

💵 $20 - $22 / hour

⏰ Full Time

🟢 Junior

🚫👨‍🎓 No degree required

👻 Ghost score 6%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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

• Prepare and coordinate reviews of group renewal information as needed at each group’s renewal time and upon special request. • Review claims submitted to UR Queues for medical necessity and on-file/not-on-file authorizations. • Make determinations for claims processing based upon coding. • Interpret medical data and coordinate utilization review processes. • Collaborate with clinical and administrative teams to support effective utilization management. • Support daily Utilization Review department operations by assisting the Senior Utilization Review Specialist. • Maintain current knowledge of UR processes and timelines. • Conduct outreach calls, collect data according to scripts, tools, and protocols, and refer to appropriate staff when indicated by workflow. • Process incoming and outgoing correspondence and faxes according to standards and timeliness guidelines. • Perform urgent scanning and document retrieval for claims routed to UR. • Interpret plan language and apply it to specialist tasks. • Process claims within BCBS Association standards.

🎯 Requirements

• One (1) or more years of experience in a healthcare payer, third-party administrator (TPA), utilization management/utilization review, health insurance, claims administration, or related healthcare environment. • Experience reviewing healthcare claims, authorizations, referrals, or medical documentation and applying established review criteria. • Ability to interpret and apply health plan language, benefit provisions, policies, and standard operating procedures to support claims and utilization review decisions. • Working knowledge of medical terminology and healthcare coding references, including CPT, HCPCS, and ICD coding systems. • Strong analytical and critical-thinking skills with the ability to make accurate, well-reasoned determinations based on available documentation. • Proficiency with Microsoft Office applications, including Word, Excel, and Outlook, and the ability to learn new systems and technology quickly. • Excellent written and verbal communication skills and the ability to interact professionally with providers, members, and internal stakeholders. • Experience in Utilization Review, Prior Authorization, Claims Adjudication, Care Management, or Medical Management functions. • Experience with BCBS Association guidelines, utilization management workflows, or health plan operations. • Experience using Javelina or other healthcare claims and case management systems. • Medical Assistant, Nursing Assistant, Home Health Aide, healthcare paraprofessional training, or related clinical background. • CPC, CCS, RHIT, RHIA, or similar coding or healthcare-related certification.