ProgenyHealth, LLC

Program Manager

• The Director of Program Management serves as a driver of strategic priorities to the CEO and Leadership Team, combining executive advisory responsibilities with program management leadership.
• This role translates leadership vision/priorities into execution, drives enterprise initiatives, identifies barriers and ensures alignment across leadership, operations, clinical, finance, product and technology leaders and functions.
• Partner with CEO, CFO and Head of Product to define and operationalize strategic priorities.
• Design & implement a system to track key initiatives, milestones, and KPIs, create clarity and ensure accountability across leadership.
• Drive cross-functional programs (growth, clinical operations, tech, and finance).
• Serve as trusted thought partner to CEO and executive team.
• Prepare board, investor, and executive meeting agendas and other materials as requested.
• Conduct analysis to inform critical strategic decisions.
• Identify & communicate progress, risks, opportunities, and dependencies.
• Identify inefficiencies and implement scalable process improvements.
• Standardize project management frameworks and reporting.
• Drive organizational discipline and follow-through.
• Reduce friction and remove barriers to execution of leadership vision/priorities.
• Ensure consistent messaging across departments and alignment on priorities.
• Facilitate leadership meetings and action tracking.
• Provide structured updates on key initiatives.
• Coordinate board materials and executive updates.
• Represent CEO in meetings when appropriate.

Director of Program Management

Associate

• The Case Management Associate will assist the Case Management department in the administration of CM functions to include telephonic outreach to members; monitoring of member eligibility; updating database information and research of support services for families.
• Works to support the Case Managers in developing open communication with members.
• Freely helps and directs callers to the correct staff member in a friendly, helpful, and courteous manner using principles of good customer service.
• Verifies member eligibility following appropriate ProgenyHealth policies, procedures, and workflows.
• Conducts outreach and follow-up calls daily to members and providers as directed by CM Leadership to: 1) Introduce Maternity CM program, mobile App and initiate intake screening tool. 2) Assist with obtaining necessary information to support CM activities (member demographics, provider contact information, researching community resources). 3) Transfer member to Case Manager or Care Coordinator for assessment completion or schedule an appointment for the member to speak with them at a later date and time.
• Documents member and provider information and calls in the medical management database as needed with member and provider data.
• Data entry into client-based systems as directed by CM Leadership.
• Completes scripted introduction calls to Provider office.
• Transfers any questions of a clinical nature from member or provider to Nurse Case Manager.
• Directs members to client point of contact for complaint calls and documents information received and notifies Supervisor.
• Assists with research of these issues if asked to do so by Supervisor.
• Attends and participates in meetings to discuss Quality Improvement updates and concerns.
• Attends ongoing training sessions related to Quality initiatives and participates in Quality Improvement projects as needed.
• Advises supervisor immediately, if a quality-of-care issue is identified.
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality and PHI disclosure.

Case Management Associate – Maternity

Medical Reviewer

• Perform clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered.
• Report to the Payment Assurance Senior Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission.
• Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines.
• Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered.
• Ensure claims analysis complies with ethical coding standards, guidelines, and regulatory requirements.
• Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered.
• Utilize Clinical Review Tools and EMR Systems.
• Research reimbursement regulations for claim payment compliance to support and validate audit findings.
• Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures.
• Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.

Clinical RN Chart Reviewer, CIC or CCS certified

Chief of Staff

• Serve as strategic partner and operational driver to the CEO and Leadership Team
• Partner with CEO, CFO and Head of Product to define and operationalize strategic priorities
• Design & implement a system to track key initiatives, milestones, and KPIs
• Drive cross-functional programs (growth, clinical operations, tech, and finance)
• Prepare board, investor, and executive meeting agendas and other materials as requested
• Conduct analysis to inform critical strategic decisions
• Identify inefficiencies and implement scalable process improvements
• Facilitate leadership meetings and action tracking

Manager

• The Case Manager will focus on empowering the members’ family to support optimal wellness while advocating for the necessary medical services across the health care continuum.
• Works in a telephonic managed care setting combining strong clinical knowledge and critical thinking to facilitate a plan of care that will ensure quality medical care for the high-risk member population serviced by ProgenyHealth based on the CMSA national standards for case management practice.

Director of Program Management

Case Management Associate – Maternity

Clinical RN Chart Reviewer, CIC or CCS certified

Chief of Staff

Nurse Case Manager – NICU