Director Of Utilization ReviewThe Director of Utilization Review is responsible for the strategic leadership, operational execution, and regulatory compliance of the Utilization Review (UR) program. This role ensures clinically sound, timely, and compliant medical necessity determinations across all lines of business, while driving integration across Claims, Appeals, Stop Loss, and vendor partners. The position also advances technology-enabled utilization management, interoperability, and population health strategies in alignment with CBG's operational and client objectives.Clinical & Operational LeadershipProvide leadership and oversight of the Utilization Review departmentEnsure consistent, evidence-based medical necessity determinationsEstablish and enforce clinical guidelines, documentation standards, and review protocolsMaintain alignment with MCG guidelines and internal clinical governance standardsClaims, Appeals & Stop Loss IntegrationEnsure seamless alignment between UR and Claims workflowsProvide clinical expertise and documentation support for Appeals processesPartner with Stop Loss teams on high-cost claim reviews and determinationsPromote end-to-end workflow efficiency across clinical and administrative functionsRegulatory Compliance & Audit ReadinessEnsure compliance with CMS, state, ERISA/non-ERISA, and accreditation requirementsMaintain audit-ready documentation and defensible clinical decisionsOversee development and accuracy of denial and determination lettersPartner with Compliance and Legal to ensure regulatory alignment across all lines of businessTechnology, Interoperability & Data StrategyDrive automation and digital workflow enhancements within UREnable interoperability across UR, Claims, Appeals, and vendor systemsSupport real-time data exchange (EDI, integration platforms)Leverage analytics to inform utilization trends, clinical outcomes, and population health initiativesQuality, Training & Performance ManagementEstablish quality assurance programs, audit processes, and performance standardsDevelop and deliver training programs for clinical and operational staffImplement dashboards and KPIs to measure productivity, compliance, and outcomesFoster a culture of continuous improvement and accountabilityRequirementsActive Registered Nurse (RN) licenseMinimum 5+ years of Utilization Review leadership experienceStrong knowledge of MCG guidelines, regulatory standards, and claims integrationPreferred experience within a TPA or health plan environmentPreferred familiarity with clinical platforms, workflow automation, and interoperability toolsCobalt Benefits Group is a trusted third-party administrator specializing in self-funded benefit plans.
With over 30 years of experience and 180+ employees, we support employers through customized health plan administration, claims management, and specialized programs including FSAs, HSAs, COBRA, and retiree billing.After a 60-day waiting period, full-time employees are eligible for a comprehensive benefits package, including:Medical, dental, and vision coverage with employer HSA contributionsCompany-paid life, AD&D, and disability insurance401(k) with up to a 6% employer matchGenerous paid time off, sick time, and 10+ paid holidaysFlexible Spending AccountsA collaborative culture with regular company events