Progyny, Inc.

Compensation

Full Description

Description: • Support all utilization review cases with an expanded focus on compliance and accreditation standards • Review and analyze member cases to determine the appropriateness and medical necessity to issue authorizations for treatment • Review clinical dashboards to understand case load, review pending cases, provide necessary documentation, and serve as liaison between different internal and external partners • 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 • 1+ year of fertility nursing experience required • Minimum 2 years of experience in UM 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) Benefits: • Paid family and parental leave • Preconception, fertility and family building benefits (including egg freezing, IVF, and adoption support) • Family and pet care fund • 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