Utilization Management Coordinator

Thank you for considering Progyny!

Progyny is looking for a Utilization Management Coordinator to support all utilization review cases. 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 and provide necessary documentation, and serve as the liaison between different internal and external partners. The ideal candidate possesses strong attention to detail, excellent verbal and written communication skills and will have deep fertility treatment knowledge.

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.

• Serves as backup for utilization associate

About you…

• Bachelor’s degree in nursing

• 1+ year of fertility nursing experience required

• Current licensed professional registered nurse

• 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'