Utilization Management Compliance Coordinator
Progyny
This listing was originally posted on Progyny's careers page. Formulate is an equal opportunity job aggregator and is not involved in the hiring process. Where salary information is estimated, it is derived from BLS industry benchmarks and may differ from actual compensation.
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.
What you’ll do…
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
About you…
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.
Utilization management experience preferred
Please note: This is not a digital nomad or remote international position; candidates must be based in the United States. Progyny is unable to provide visa sponsorship for this position. Candidates must be authorized to work in United States without the need for sponsorship, now or in the future.
About Progyny:
Progyny (Nasdaq: PGNY) is a global leader in women’s health and family building solutions, trusted by the nation’s leading employers, health plans and benefit purchasers. We envision a world where everyone can realize dreams of family and ideal health. Our outcomes prove that comprehensive, inclusive and intentionally designed solutions simultaneously benefit employers, patients and physicians.
Our benefits solution empowers patients with concierge support, coaching, education, and digital tools; provides access to a premier network of fertility and women's health specialists who use the latest science and technologies; drives optimal clinical outcomes; and reduces healthcare costs.
Our mission is to empower healthier, supported journeys through transformative fertility, family building and women’s health benefits.
Headquartered in New York City, Progyny has been recognized for its leadership and growth as a TIME100 Most Influential Company, CNBC Disruptor 50, Modern Healthcare's Best Places to Work in Healthcare, Forbes' Best Employers, Financial Times Fastest Growing Companies, Inc. 5000, Inc. Power Partners, and Crain's Fast 50 for NYC. For more information, visit www.progyny.com.
Our perks:
In compliance with New York City's Wage Transparency Law, the hourly salary [wage] range for NYC-based applicants is: $35 - 45/hour. There are a variety of factors that go into determining a salary range, including but not limited to external market benchmark data, geographic location, and years of experience sought/required. Progyny offers a total compensation package comprised of base salary, cash bonus, and equity.
Progyny is proud to be an Equal Opportunity and Affirmative Action employer. We respect and seek to empower each individual and support the diverse cultures, perspectives, skills and experiences within our workforce. All qualified applicants will receive consideration for employment without regard to race, creed, color, religion, sex, sexual orientation, gender identity or expression, national origin, disability, age, genetic information, marital status, pregnancy or related condition, status as a protected veteran, criminal history consistent with legal requirements or any other basis protected by law.
If you are an individual with a disability and need assistance or an accommodation during the recruiting process, please send an e-mail to apply@progyny.com.
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