Utilization Management Compliance Coordinator

Job description

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...