Utilization Management Compliance Coordinator
About The Position
Thank you for considering Progyny! Progyny is looking for a Utilization Management Coordinator to support all utilization review cases with an expanded focus on compliance and accreditation standards. This coordinator will be directly responsible for reviewing and analyzing member cases to determine the appropriateness and medical necessity to issue authorizations for treatment. This person will review clinical dashboards to understand case load, review pending cases, provide necessary documentation, and serve as the liaison between different internal and external partners including providers, payers, and compliance teams; monitor and interpret accreditation standards (e.g., URAC, NCQA) and integrate them into UM workflows, conduct internal audits and readiness assessments for accreditation reviews, collaborate with Legal and Compliance teams to update clinical guidelines and reviewer protocols, maintain awareness of licensure requirements and state-specific UM regulations.
Requirements
- Bachelor’s degree in nursing preferred
- 1+ year of fertility nursing experience
- Minimum 2 years of experience in compliance or accreditation preparation preferred
- Current licensed professional registered nurse
- Familiarity with URAC/NCQA standards and state-specific UM regulations.
- Experience in audit preparation and regulatory reporting.
- Knowledge of CPT, HCPCS, ICD-10 codes and understanding of medical terminology
- Strong communication and presentations skills.
- Strong attention to detail
- Excellent written and verbal communication skills
- Ability to communicate effectively and thoughtfully with providers and patients regarding authorization requests and determinations
- Ability to work independently with minimal supervision and escalate when necessary
- Strong multi-tasking and prioritization skills
- Experience working with CRM platforms (specifically Salesforce) and reporting / dashboard management.
- Experience with CRM platforms / JIRA as it relates to bug reporting
- Experience and facility working with Microsoft Office Suite (Excel, Word, PowerPoint, Outlook)
- Ability and willingness to learn new programs and platforms to optimize UM workflow/Member experience.
Nice To Haves
- Utilization management experience preferred
Responsibilities
- Provide timely medical reviews with clinical determinations based on evidence-based criteria and necessary authorization guidelines
- Conduct daily, weekly, and quarterly reporting in coordination with all service level agreements with Progyny federal and non-federal clients
- Outreach and educate providers to obtain all required documentation for authorization requests
- Coordinate and schedule peer-to-peer review and appeal appointments between physicians within necessary timelines; track and record quarterly compensation/reimbursement
- Coordinate with Independent Review Organization to ensure the timely appeals processing and auditing of Utilization case management for specific states.
- Organize and present quarterly and annual audits to ensure adherence to requirements determined for cases.
- Processes all incoming and outgoing correspondence/faxes in accordance with required standards and within respective timeliness guidelines
- Manage a multi-step workflow to ensure all tasks are appropriately delegated to proper workstream.
- Communicate and escalate potential enhancements to both internal and external processes.
- Categorize documentation while remaining in accordance with PHI / HIPAA restrictions.
- Ensure UM practices align with federal and state compliance standards, including turnaround times (TAT), member notification protocols, and appeals processes.
- Monitor and interpret accreditation requirements (e.g., URAC, NCQA) and integrate them into UM workflows and documentation standards.
- Conduct internal audits and readiness assessments for accreditation reviews, including documentation of nurse approvals and medical necessity determinations.
- Collaborate with Legal and Compliance teams to update clinical guidelines and reviewer protocols in response to regulatory changes.
- Maintain licensure awareness and state-specific requirements for nurse reviewers, especially in compact and non-compact states
Benefits
- Family friendly benefits: Paid family and parental leave, preconception, fertility and family building benefits (including egg freezing, IVF, and adoption support), family and pet care fund, and Parents’ Employee Affiliation Group
- Menopause and midlife care
- Health, dental, vision and life insurance options for employees and family
- Free in-person, virtual and text-based mental health and wellness support
- Paid time off, including vacation, sick leave, personal days and summer flex time
- Company equity
- Bonus program
- 401(k) plan with company match
- Access to on-demand legal and financial advice
- Learning and development programs to help you grow professionally and a mentorship program
- Company social events to include annual volunteer day and donation matching
- Flex days (3 days a week in the office) and onsite meals and snacks for employees reporting into our NY office
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
251-500 employees
