Utilization Management Clinical Coordinator

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct timely medical evaluations and clinical assessments in accordance with evidence-based criteria and authorization protocols.

• Perform daily, weekly, and quarterly reporting aligned with client service-level agreements.

• Engage with and educate healthcare providers to gather necessary authorization documentation.

• Organize and arrange peer-to-peer reviews and appeal meetings between physicians.

• Monitor and document quarterly compensation and reimbursement metrics.

• Collaborate with Independent Review Organizations to guarantee prompt appeals processing and audit utilization case management for designated states.

• Plan and deliver quarterly and annual audits.

• Manage incoming and outgoing correspondence and faxes adhering to established standards and timelines.

• Oversee multi-step workflows and assign tasks to the appropriate workstream.

• Communicate and escalate potential improvements to both internal and external processes.

• Classify documentation in compliance with PHI/HIPAA regulations.

• Act as a backup for the utilization associate.

⛳️ Requirements

• Bachelor’s degree in nursing.

• A minimum of 3 years of experience in fertility nursing.

• Current license as a professional registered nurse.

• Familiarity with CPT, HCPCS, and ICD-10 coding systems.

• Comprehensive understanding of medical terminology.

• Exceptional communication and presentation abilities.

• High level of attention to detail.

• Excellent written and verbal communication skills.

• Capability to communicate effectively and thoughtfully with providers and patients regarding authorization requests and decisions.

• Ability to work independently with minimal oversight and escalate issues when necessary.

• Strong multitasking and prioritization capabilities.

• Experience with CRM platforms, particularly Salesforce, as well as reporting and dashboard management.

• Experience with CRM platforms/JIRA concerning bug reporting.

• Proficient in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook.

• Willingness to learn new programs and platforms to enhance the UM workflow and member experience.

• Preferred experience in utilization management.

• Must reside in the United States.

• Must have authorization to work in the United States without sponsorship, both now and in the future.

🏝️ Benefits

• Paid family and parental leave.

• Preconception, fertility, and family building benefits, including egg freezing, IVF, and adoption assistance.

• Fund for family and pet care.

• Parents’ Employee Affiliation Group.

• Support for menopause and midlife care.

• Health, dental, vision, and life insurance options for employees and their families.

• Free in-person, virtual, and text-based mental health and wellness support.

• Paid time off, which includes vacation, sick leave, personal days, and summer flex time.

• Company equity.

• Bonus program.

• 401(k) plan with company matching.

• Access to on-demand legal and financial counsel.

• Opportunities for learning and development.

• Mentorship program.

• Company social events, including an annual volunteer day and donation matching.

• Flexible workdays (3 days a week in the office).

• Onsite meals and snacks for employees working in our NY office.