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

• Handle high-volume inbound calls with professionalism, empathy, and accuracy. • Provide clear, accurate information regarding health insurance benefits, claims, billing, and eligibility. • Assist members in navigating online resources and submitting requests. • Document all call interactions in customer management systems in compliance with company and regulatory requirements. • Adhere to call handling standards, including average handle time, quality scores, and first call resolution targets. • Follow compliance guidelines including HIPAA, CMS, and state-specific regulations. • Escalate complex issues appropriately to ensure timely resolution. • Stay current with updates to health plan policies, systems, and processes. • Contribute to continuous improvement by identifying trends and opportunities for enhanced customer experience.

• Handle high-volume inbound calls with professionalism, empathy, and accuracy. • Provide clear, accurate information regarding health insurance benefits, claims, billing, and eligibility. • Assist members in navigating online resources and submitting requests. • Document all call interactions in customer management systems in compliance with company and regulatory requirements. • Adhere to call handling standards, including average handle time, quality scores, and first call resolution targets. • Follow compliance guidelines including HIPAA, CMS, and state-specific regulations. • Escalate complex issues appropriately to ensure timely resolution. • Stay current with updates to health plan policies, systems, and processes. • Contribute to continuous improvement by identifying trends and opportunities for enhanced customer experience.

• Audit, review, and adjust medical, dental, and flexible spending accounts and Health Reimbursement Account claims. • Review, apply and create refund letters for all lines of business to members and providers. • Reprocess payments when necessary. • Communicate with members, providers, employer group contacts, and other inquirers pertaining to specific refund questions. • Review plan documents for various groups to research and resolve claim processing questions and issues. • Act with urgency to respond to inquiries regarding refund request status-including research and resolution regarding outstanding request. • Perform other related duties, as assigned.

• Audit, review, and adjust medical, dental, and flexible spending accounts and Health Reimbursement Account claims. • Review, apply and create refund letters for all lines of business to members and providers. • Reprocess payments when necessary. • Communicate with members, providers, employer group contacts, and other inquirers pertaining to specific refund questions. • Review plan documents for various groups to research and resolve claim processing questions and issues. • Act with urgency to respond to inquiries regarding refund request status-including research and resolution regarding outstanding request. • Perform other related duties, as assigned.

• 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.

• 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.

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

• Join our team at Company and build a meaningful career in employee benefits solutions. • Review claims in utilization review queues for medical necessity and authorization status. • Support the daily operations of the Utilization Review department by assisting senior UR team members. • Conduct outreach calls and collect data using established scripts, tools, and protocols. • Process correspondence and faxes in accordance with timeliness standards. • Perform clerical and administrative tasks, including scanning, document retrieval, and urgent claims processing support. • Communicate clearly, professionally, and courteously with internal and external stakeholders. • Provide written direction to other team members to support accurate claims processing. • Maintain current knowledge of Standard Operating Procedures and member benefits. • Ensure compliance with BCBS Association standards and company policies. • Complete other related duties and projects as assigned.

• 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 • 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 • Ensure compliance with CMS, state, ERISA/non-ERISA, and accreditation requirements • Drive automation and digital workflow enhancements within UR • Enable interoperability across UR, Claims, Appeals, and vendor systems • Leverage analytics to inform utilization trends, clinical outcomes, and population health initiatives • Establish quality assurance programs, audit processes, and performance standards

• 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 • 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 • 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 • 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 • 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