Healthcare Utilization Review Specialist

Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA)

. Prepare and coordinate reviews of group renewal information as needed at each group’s renewal time and upon special request.

Posted 9/18/2026full-timeRemote • New Hampshire • United StatesJunior💰 $20 - $22 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Review processes, including claims processing, medical necessity determinations, and application of health plan language. Proficient in analyzing healthcare claims and collaborating with clinical teams to ensure effective utilization management.

Highest-signal resume keywords

Utilization Review ExperienceHealthcare Claims ReviewMedical Terminology KnowledgeCPT/HCPCS/ICD Coding ProficiencyBCBS Association Guidelines Familiarity

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingUtilization ManagementData InterpretationAnalytical SkillsHealthcare CodingMedical Documentation ReviewBenefit Provisions ApplicationClaims AdjudicationPrior AuthorizationCare Management

Soft Skills

Critical ThinkingCommunication SkillsProfessional Interaction

Tools & Technologies

Microsoft OfficeJavelinaHealthcare Claims Systems

Certifications & Qualifications

CPCCCSRHITRHIA

Industry Keywords

Healthcare PayerThird-Party AdministratorUtilization ManagementHealth InsuranceClaims Administration

About the role

Key responsibilities & impact

Prepare and coordinate reviews of group renewal information as needed at each group’s renewal time and upon special request.
Review claims submitted to UR Queues for medical necessity and on-file/not-on-file authorizations.
Make determinations for claims processing based upon coding.
Interpret medical data and coordinate utilization review processes.
Collaborate with clinical and administrative teams to support effective utilization management.
Support daily Utilization Review department operations by assisting the Senior Utilization Review Specialist.
Maintain current knowledge of UR processes and timelines.
Conduct outreach calls, collect data according to scripts, tools, and protocols, and refer to appropriate staff when indicated by workflow.
Process incoming and outgoing correspondence and faxes according to standards and timeliness guidelines.
Perform urgent scanning and document retrieval for claims routed to UR.
Interpret plan language and apply it to specialist tasks.
Process claims within BCBS Association standards.

Requirements

What you’ll need

One (1) or more years of experience in a healthcare payer, third-party administrator (TPA), utilization management/utilization review, health insurance, claims administration, or related healthcare environment.
Experience reviewing healthcare claims, authorizations, referrals, or medical documentation and applying established review criteria.
Ability to interpret and apply health plan language, benefit provisions, policies, and standard operating procedures to support claims and utilization review decisions.
Working knowledge of medical terminology and healthcare coding references, including CPT, HCPCS, and ICD coding systems.
Strong analytical and critical-thinking skills with the ability to make accurate, well-reasoned determinations based on available documentation.
Proficiency with Microsoft Office applications, including Word, Excel, and Outlook, and the ability to learn new systems and technology quickly.
Excellent written and verbal communication skills and the ability to interact professionally with providers, members, and internal stakeholders.
Experience in Utilization Review, Prior Authorization, Claims Adjudication, Care Management, or Medical Management functions.
Experience with BCBS Association guidelines, utilization management workflows, or health plan operations.
Experience using Javelina or other healthcare claims and case management systems.
Medical Assistant, Nursing Assistant, Home Health Aide, healthcare paraprofessional training, or related clinical background.
CPC, CCS, RHIT, RHIA, or similar coding or healthcare-related certification.

Benefits

Comp & perks

Website LinkedIn All Job Openings 51 - 200 employees 💼 Consulting ⚖️ Legal 🛡️ Insurance Consulting
Legal
Insurance Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA) is a full service Third Party Administrator (TPA) that specializes in the customization, marketing, and operation of self-funded employee benefit plans. With over 30 years of experience and a team of over 195 employees, CBG provides a wide array of products and services including self-funded medical and dental plans, Flexible Spending Accounts, Health Reimbursement Arrangements, and COBRA management. CBG aims to assist employers in building custom benefit plans while managing costs and ensuring compliance with regulations.