Utilization Management Clinical Coordinator

🔥 13 hours ago

🇺🇸 United States – Remote

💵 $85k - $100k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Progyny, Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2015

💼 Consulting

🛡️ Insurance

🏥 Healthcare

Consulting • Insurance • Healthcare

Progyny, Inc. is a company that provides comprehensive reproductive health benefits with a focus on fertility, family building, and women's reproductive health. Their services include flexible and equitable fertility benefits such as IVF, IUI, adoption, and surrogacy, catering to a global workforce. Progyny is dedicated to achieving superior clinical outcomes and exceptional member experiences through their data-driven model. They offer an extensive network of providers, ensuring high-quality, accessible care. Progyny supports over 460 companies with varied industries, aiming to redefine employer benefits with solutions that encompass every stage of life, from preconception to menopause.

📋 Description

• Provide timely medical reviews and clinical determinations based on evidence-based criteria and authorization guidelines • Conduct daily, weekly, and quarterly reporting in coordination with client service-level agreements • Outreach to and educate providers to obtain required authorization documentation • Coordinate and schedule peer-to-peer reviews and appeal appointments between physicians • Track and record quarterly compensation/reimbursement • Coordinate with Independent Review Organizations to ensure timely appeals processing and audit utilization case management for specific states • Organize and present quarterly and annual audits • Process incoming and outgoing correspondence and faxes within required standards and timelines • Manage multi-step workflows and delegate tasks to the appropriate workstream • Communicate and escalate potential enhancements to internal and external processes • Categorize documentation in accordance with PHI/HIPAA restrictions • Serve as backup for the utilization associate

🎯 Requirements

• Bachelor’s degree in nursing • 3+ year of fertility nursing experience • Current licensed professional registered nurse • Knowledge of CPT, HCPCS, and ICD-10 codes • Understanding of medical terminology • Strong communication and presentation 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 multitasking 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 with Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook • Ability and willingness to learn new programs and platforms to optimize UM workflow/member experience • Utilization management experience preferred • Must be based in the United States • Must be authorized to work in the United States without sponsorship, now or in the future

🏖️ Benefits

• Paid family and parental leave • Preconception, fertility and family building benefits, including egg freezing, IVF, and adoption support • Family and pet care fund • 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 • Mentorship program • Company social events, including annual volunteer day and donation matching • Flex days (3 days a week in the office) • Onsite meals and snacks for employees reporting into our NY office