Director, Utilization Review

Description

The 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 Leadership:

• 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

Claims, Appeals & Stop Loss Integration:

• 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

Regulatory Compliance & Audit Readiness:

• 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

Technology, Interoperability & Data Strategy:

• 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

Quality, Training & Performance Management:

• 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

• 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

Why Join Cobalt Benefits Group?

Cobalt 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 contributions
• Company-paid life, AD&D, and disability insurance
• 401(k) with up to a 6% employer match
• Generous paid time off, sick time, and 10+ paid holidays
• Flexible Spending Accounts
• A collaborative culture with regular company events