Utilization Review Nurse

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

Utilization Review Nurse at Cobalt Benefits Group reviewing healthcare services for medical necessity. Collaborating with healthcare staff to ensure effective patient care and compliance with benefit requirements.

Posted 6/26/2026full-timeRemote • Texas • 🇺🇸 United StatesMid-LevelSenior💰 $90,000 - $98,000 per yearWebsite

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

Current, unrestricted RN license (State license required).
Minimum 3 years of clinical nursing experience.
Minimum 1 year of Utilization Management (UM) or Utilization Review (UR) experience.
Strong analytical, critical thinking, and problem-solving skills.
Proficiency in Microsoft Office Suite (Excel, Word, Outlook) and familiarity with utilization management systems.
Excellent verbal and written communication skills, with the ability to interact effectively with internal and external stakeholders.
Strong organizational and time management skills, with the ability to handle multiple priorities independently.

Benefits

Comp & perks

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51 - 200 employees
Who We Are:

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Hard Skills & Tools

clinical nursing experienceUtilization ManagementUtilization Reviewmedical necessity reviewscase managementprocess improvementdocumentation complianceanalytical skillscritical thinkingproblem-solving

Soft Skills

verbal communicationwritten communicationorganizational skillstime managementinterpersonal skills

Certifications

RN license