Care Optimization: Utilization Review Specialist

Socket.dev; Orlando (FL); On-site; USD 52,000 - 76,000; Full time

Benefits offered by this job

Health insurance

401(k) with employer-match

Paid holidays

Tuition reimbursement

Flexible Spending Accounts

Job summary

Cobalt Benefits Group is seeking a Healthcare Utilization Review Specialist in Orlando to ensure proper utilization management of self-funded benefits. You will review claims for medical necessity, verify authorizations, and coordinate with clinical teams to support efficient claims processing.

The role requires detail-oriented para-professionals with knowledge of medical terminology and insurance processes. Strong MS Office skills and clear stakeholder communication are essential.

Qualifications

• Prior training in coding, insurance, basic medical vocabulary or related para-professional training (preferred)
• Fluent computer skills including MS Office and Internet applications
• Strong reading comprehension and self-direction

Responsibilities

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

Skills

MS Office

Reading comprehension

Self-motivated

Education

Medical assistant, home health aide, nursing assistant training or certification

Tools

MS Office

Job description

Cobalt Benefits Group is seeking a Healthcare Utilization Review Specialist in Orlando to ensure proper utilization management of self-funded benefits. You will review claims for medical necessity, verify authorizations, and coordinate with clinical teams to support efficient claims processing.

The role requires detail-oriented para-professionals with knowledge of medical terminology and insurance processes. Strong MS Office skills and clear stakeholder communication are essential.