Director, Utilization Review

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

Director of Utilization Review leading Utilization Review program at Cobalt Benefits Group. Ensuring regulatory compliance and integration of clinical guidelines and workflows across departments.

Posted 6/19/2026full-timeRemote • Vermont • 🇺🇸 United StatesLead💰 $135,000 - $155,000 per yearWebsite

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
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
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All Job Openings
51 - 200 employees
Who We Are:

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Hard Skills & Tools

Utilization Reviewclinical guidelinesdocumentation standardsaudit processesworkflow automationdata exchangeanalyticsquality assuranceKPI implementationclinical expertise

Soft Skills

leadershipoversightcommunicationcollaborationcontinuous improvementaccountabilitytraining developmentproblem-solvingorganizational skillsinterpersonal skills

Certifications

Registered Nurse (RN) license