Utilization Review Nurse

Join our team at Cobalt Benefits Group and start an exciting new career in employee benefits solutions. As a Utilization Review (UR) Nurse, you’ll play an important role in helping us offer customized, self-funded insurance options to our clients and members.

Reporting to the UR Manager, the UR Nurse performs utilization and concurrent review of cases using Milliman criteria, including but not limited to: Acute inpatient stays/ surgeries, acute inpatient mental health/ substance abuse stays, elective inpatient surgery admissions, outpatient surgeries, high-cost infusions/ injections, physical therapy, home health services, home infusion services, infertility treatment, and durable medical equipment.

The UR Nurse is also responsible for helping lead the Utilization team's Intake Analysts with administrative responsibilities related to various stages of the Company’s standard medical review practices. In short, this team reviews medical records and builds cases to further examine how our group health plans are required to pay or adjudicate certain medical claims.

Responsibilities:

• Perform medical necessity review for services that require prior authorization utilizing specific criteria.
• Discuss cases with healthcare professionals to gather necessary information to review the requested services or to give verbal determination on a case.
• Request clinical information necessary to review requested services.
• Determine need, if any, for intervention and discussion with Case Managers.
• Maintain accurate and appropriate documentation.
• Consult with the Physician Reviewers as needed to troubleshoot difficult or complex cases.
• Review high-cost prescription overrides as necessary.
• Performs other duties as assigned.

• A current, unrestricted RN license.
• 3+ years of Med Surg clinical experience.
• 1 year or more of UM/UR experience required including experience performing admission and continued inpatient stay reviews using medical criteria.
• Demonstrate a proficiency in computer skills – Windows, Word, Excel, Outlook, clinical platforms, internet searches.
• Knowledge of ICD 10 codes and CPT codes.
• Detail oriented, self-sufficient and decisive.
• Excellent organizational and communication skills.
• Ability to be flexible and work in a fast-paced office environment.
• Ability to prioritize a high volume of work.
• Experience in discharge planning and/or chart review.
• Experience in prior authorizations or related function (utilization review, coverage determination, etc.).
• Experience with utilization review for an insurance company or in a managed care environment.
• Familiarity with MCG criteria guidelines.

Benefits:

After successfully completing a 60-day waiting period, every Full-time employee has access to our comprehensive benefits package, including:

• Fantastic medical, dental, and vision insurance- twice annual employer HSA contribution, covering 50% of the plan’s annual deductible!
• Company paid 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!)
• 10+ paid holidays
• Generous paid vacation and sick time
• Lots of fun company events

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/.