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