Healthcare Utilization Review Specialist

Join our team at Company and build a meaningful career in employee benefits solutions. As a Healthcare Utilization Review Specialist, you’ll play a vital role in ensuring our clients and members receive the right care at the right time through customized, self-funded insurance programs. You’ll review claims for medical necessity, verify authorizations, and collaborate across clinical and administrative teams to support effective utilization management.

Position Summary

Reporting to the Utilization Review Manager, the Utilization Review Specialist will coordinate reviews of group renewal information, process claims for medical necessity, and determine whether authorizations are on file. Make determinations for claims processing based upon coding. This position involves interpretation of medical data, coordination of review processes, and collaboration with clinical and administrative teams to support effective utilization management. This role is ideal for detail-oriented healthcare para-professionals who want to apply their knowledge of medical terminology and insurance processes in a supportive, team-driven environment.

Key Responsibilities

• Review claims in utilization review queues for medical necessity and authorization status; determine appropriate processing based on coding and plan language.
• Support the daily operations of the Utilization Review department by assisting senior UR team members with case review activities.
• Conduct outreach calls and collect data using established scripts, tools, and protocols, while maintaining productivity and service standards.
• Process correspondence and faxes in accordance with timeliness standards; escalate to clinical team members when appropriate.
• Perform clerical and administrative tasks, including scanning, document retrieval, and urgent claims processing support.
• Communicate clearly, professionally, and courteously with internal and external stakeholders to resolve issues.
• Provide written direction to other team members (nurses, claims auditors) to support accurate claims processing.
• Maintain current knowledge of Standard Operating Procedures, member benefits, rights, and responsibilities.
• Ensure compliance with BCBS Association standards and company policies.
• Complete other related duties and projects as assigned.

• (Prior training in coding, insurance, basic medical vocabulary, training or certification in these roles preferred but not required:) Medical assistant, home health aide, nursing assistant, or other similar health care para-professional training or certification.
• Fluent computer skills including MS Office (Word, Excel, and Outlook) and Internet applications.
• Strong reading comprehension
• Self-motivated, self-directed, operates without constant guidance.
• Must be able to make sound logical decisions and articulate the reasoning.

Benefits:

After successfully completing a waiting period, eligible Full-time employees have access to our comprehensive benefits package, including:

• Fantastic medical, dental, and vision insurance*
• Twice annual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible!
• Company provided Basic Life and AD&D
• Company paid Short-Term and Long-Term Disability**
• Flexible Spending Accounts*
• 401(k) Retirement Plan with up to a 6% employer-match** WOW! (100% fully vested after 3 years)
• 10+ paid holidays
• Generous paid vacation and sick time
• Annual Volunteer Paid Day
• Annual Tuition Reimbursement
• Annual Health and Wellness Reimbursement
• Lots of fun company events

*60 day waiting period

**90 day waiting period

Who We are:

As a trusted third-party administrator (TPA) specializing in self-funded benefit plans, Cobalt Benefits Group (CBG) is committed to helping employers find high-quality coverage at a cost they can afford. We administer self-funded insurance benefits through our three companies: EBPA, Blue Benefit Administrators of Massachusetts, and CBA Blue.

With over 30 years of experience and a dedicated team of more than 200 employees, we work collaboratively to build customized self-funded health plans, manage claim payments and disputes, and administer other specialized programs such as FSAs, HSAs, COBRA, and retiree billing. Join us as we match employers across our region with the right solutions for their employee benefit needs. To learn more about working at CBG, visit https://www.cobaltbenefitsgroup.com/careers/.