Utilization Review Nurse

Job description

Utilization Review Nurse (Ur Nurse) Join our team at Cobalt Benefits Group and start an exciting new career in employee benefits solutions. As a Utilization Review Nurse (UR Nurse), you'll play an important role in helping us offer customized, self-funded insurance options to our clientsand members. The UR Nurse is responsible for reviewing clinical information to determine the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and levels of care in accordance with established criteria, payer guidelines, and organizational policies. This role involves evaluating healthcare services and facilities under the provisions of applicable health benefit plans to ensure quality and cost-effective patient care. The UR Nurse collaborates closely with intake staff, physicians, specialists, case managers, and other members of the care team to facilitate timely and effective care authorizations, transitions, and utilization determinations. Strong communication, clinical judgment, and attention to detail are essential to ensure services meet both clinical standards and benefit requirements. Responsibilities • Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria. • Conduct medical necessity reviews for services requiring prior authorization, applying utilization-specific criteria. • Request and evaluate clinical information needed to review requested services. • Discuss cases and determinations with healthcare professionals and physician reviewers. • Identify cases requiring intervention and collaborate with Case Managers as needed. • Maintain appropriate and accurate documentation, ensuring compliance with audit standards. • Participate in team meetings, educational sessions, and related activities. • Review medical claims and pre-determinations for medical necessity and appropriateness. • Identify opportunities for process improvement and enhance communication among departments. • Consult with Physician Reviewers for complex or challenging cases. Requirements • Current, unrestricted RN license (State license required). • Minimum 3 years of clinical nursing experience. • Minimum 1 year of Utilization Management (UM) or Utilization Review (UR) experience. • Strong analytical, critical thinking, and problem-solving skills. • Proficiency in Microsoft Office Suite (Excel, Word, Outlook) and familiarity with utilization management systems. • Excellent verbal and written communication skills, with the ability to interact effectively with internal and external stakeholders. • Strong organizational and time management skills, with the ability to handle multiple priorities independently. Preferred Qualifications • Experience with Milliman or Aetna criteria. • Background in healthcare administration, medical necessity determination, or benefits management. • Experience in data interpretation and medical trend analysis. Work Environment & Physical Demands • Prolonged periods of sitting may be required. • Regular use of a computer, keyboard, and mouse is necessary; reasonable accommodations will be provided upon request. • Employees should ensure an ergonomically appropriate desk and chair setup. • Comfort with being on camera for virtual meetings (e.g., Microsoft Teams) 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** (100% fully vested after 3 years) • 10+ paid holidays • Half-day Summer Fridays • Generous paid vacation and sick time • Annual paid Volunteer Day • Annual Tuition reimbursement • Annual Health and Wellness reimbursement • Lots of fun company events Benefit Waiting Period Notes: *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 four companies: EBPA, Blue Benefit Administrators of Massachusetts, CBA Blue, and Great Bay Administrators. With over 30 years of experience and a dedicated team of nearly 300 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. Cobalt Benefits Group is one of the fastest growing TPA's in the country and the fastest growing in New England. Join us as we match employers across our region with the right solutions for their employee benefit needs.