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

Representative

• Assist internal and external customers with COBRA and Direct Bill related inquiries.
• Review and understand new and existing Federal COBRA laws and regulations as they relate to our customers and clients.
• Processing Enrollments, Elections for our COBRA and Direct Bill members.
• Processing COBRA and Direct Bill premium payments.
• Request and process COBRA and Direct Bill renewal rates and plan changes.
• Assist in Client’s Implementation and Open enrollments.
• Perform Audits on COBRA and Direct Bill changes and accounts.
• Review and properly execute COBRA appeals for reinstatement.
• Provide professional and quality services to our clients.
• Aid in special projects and other duties as assigned.

Direct Bill Representative

Customer Support

• Handle high-volume inbound calls with professionalism, empathy, and accuracy.
• Provide clear, accurate information regarding health insurance benefits, claims, billing, and eligibility.
• Assist members in navigating online resources and submitting requests.
• Document all call interactions in customer management systems in compliance with company and regulatory requirements.
• Adhere to call handling standards, including average handle time, quality scores, and first call resolution targets.
• Follow compliance guidelines including HIPAA, CMS, and state-specific regulations.
• Escalate complex issues appropriately to ensure timely resolution.
• Stay current with updates to health plan policies, systems, and processes.
• Contribute to continuous improvement by identifying trends and opportunities for enhanced customer experience.

Customer Service Representative

General

• Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria.
• Conduct medical necessity reviews for services requiring prior authorization, applying utilization-specific criteria.
• Request and evaluate clinical information needed to review requested services.
• Discuss cases and determinations with healthcare professionals and physician reviewers.
• Identify cases requiring intervention and collaborate with Case Managers as needed.
• Maintain appropriate and accurate documentation, ensuring compliance with audit standards.
• Participate in team meetings, educational sessions, and related activities.
• Review medical claims and pre-determinations for medical necessity and appropriateness.
• Identify opportunities for process improvement and enhance communication among departments.
• Consult with Physician Reviewers for complex or challenging cases.

Utilization Review Nurse

Claims Specialist

• Ensure accuracy of claims adjudication while maintaining quality and turn around goals.
• Adjudicate medical, dental and vision claims.
• Review plan documents for various groups to apply appropriate benefits to claims being adjudicated.
• Prioritize assigned claims by adjudicating oldest claims first.
• Communicate effectively with internal auditors and management team.
• Perform other related duties, as assigned.

Healthcare Benefits Claims Examiner

• Audit, review, and adjust medical, dental, and flexible spending accounts and Health Reimbursement Account claims.
• Review, apply and create refund letters for all lines of business to members and providers.
• Reprocess payments when necessary.
• Communicate with members, providers, employer group contacts, and other inquirers pertaining to specific refund questions.
• Review plan documents for various groups to research and resolve claim processing questions and issues.
• Act with urgency to respond to inquiries regarding refund request status-including research and resolution regarding outstanding request.
• Perform other related duties, as assigned.

Healthcare Claims Refund Specialist

Analyst

• Provide lifecycle service support to clients, from scheduled file loads to ongoing support and troubleshooting
• Act as a resource for enrollment and claims teams to improve accuracy and ease of use for internal and external processes
• Responsible for EDI file processing and data reconciliation
• Review and action all enrollment source specific reports
• Provide analysis, support, and guidance on complex EDI transfers
• Review EDI processes and systems to improve submission rate and quality of each encounter with EDI
• Act as backup for teammates
• Other projects as assigned by management

EDI Analyst, Level 1

Director

• 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
• Partner with Compliance and Legal to ensure regulatory alignment across all lines of business
• 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

Director, Utilization Review

• 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
• Ensure compliance with CMS, state, ERISA/non-ERISA, and accreditation requirements
• Drive automation and digital workflow enhancements within UR
• Enable interoperability across UR, Claims, Appeals, and vendor systems
• Leverage analytics to inform utilization trends, clinical outcomes, and population health initiatives
• Establish quality assurance programs, audit processes, and performance standards

• 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