FREE ACCESS
5,000–10,000 jobs/day
See all jobs on JobTailor
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Director, Utilization Review
Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA)Director of Utilization Review responsible for leadership and compliance of Utilization Review program at Cobalt Benefits Group. Ensures timely, compliant medical necessity determinations across all business lines.
About the role
Key responsibilities & impact- 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
Requirements
What you’ll need- 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
Comp & perks- Website
- All Job Openings
- 51 - 200 employees
- Who We Are:
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Utilization Reviewclinical guidelinesdocumentation standardsaudit processesdata exchangeanalyticsquality assuranceworkflow automationinteroperabilityperformance standards
Soft Skills
leadershipcommunicationcollaborationtrainingcontinuous improvementaccountabilityclinical expertiseoversightproblem-solvingefficiency
Certifications
Registered Nurse (RN) license