Case Manager, Patient Financial Services - Appeals

Memorial Sloan Kettering Cancer Center; New York (NY); Hybrid; USD 125,000 - 201,000; Full time

Job summary

Memorial Sloan Kettering Cancer Center, New York, NY, seeks a Case Manager in Patient Financial Services to navigate payer requirements, review medical necessity, and manage appeals for medically necessary treatment.

The role involves collaborating with physicians, care teams, patients, and insurers to obtain documentation, communicate status, and ensure timely access to care while maintaining compliance with regulations and internal standards. Hybrid work schedule available.

Qualifications

• Review medical records to assess medical necessity and support authorization/appeals requests.
• Facilitate insurance appeals and denial management activities, including preparation of supporting clinical documentation.
• Apply Medicare, Medicaid, and payer-specific guidelines when evaluating coverage and medical necessity criteria.
• Collaborate with physicians and care teams to obtain letters of medical necessity and other supporting documentation.
• Communicate with patients, providers, pharmacies, PBMs, and insurance representatives regarding authorization status, appeals, coverage determinations, and benefit information.
• Document case activity, authorization outcomes, payer communications, and appeal strategies in accordance with departmental standards.
• Serve as a liaison between patients, clinical teams, and payers to help ensure timely access to treatment.
• Research and interpret payer policies, coverage requirements, clinical guidelines, and supporting medical literature to strengthen appeals.
• Manage a high-volume caseload while tracking deadlines, prioritizing urgent cases, and ensuring compliance with regulatory requirements.

Responsibilities

• Review medical records, clinical documentation, and treatment plans to assess medical necessity and support authorization/appeals requests.
• Facilitate insurance appeals and denial management activities, including preparation of supporting clinical documentation.
• Apply Medicare, Medicaid, and payer-specific guidelines when evaluating coverage and medical necessity criteria.
• Collaborate with physicians and care teams to obtain letters of medical necessity and other supporting documentation.
• Communicate with patients, providers, pharmacies, PBMs, and insurance representatives regarding authorization status, appeals, coverage determinations, and benefit information.
• Document case activity, authorization outcomes, payer communications, and appeal strategies in accordance with departmental standards.
• Serve as a liaison between patients, clinical teams, and payers to help ensure timely access to treatment.
• Research and interpret payer policies, coverage requirements, clinical guidelines, and supporting medical literature to strengthen appeals.
• Manage a high-volume caseload while tracking deadlines, prioritizing urgent cases, and ensuring compliance with regulatory requirements.

Skills

Clinical nursing experience

Utilization management

Appeals/denials management

Medicare/Medicaid knowledge

Regulatory compliance

InterQual/Milliman criteria

Communication skills

Payer-specific coverage knowledge

Education

Bachelor’s degree in Nursing

Tools

EHR systems

Payer portals

Prior authorization systems

Microsoft Office

Job description

About Us

The people of Memorial Sloan Kettering Cancer Center (MSK) are united by a singular mission: ending cancer for life. Our specialized care teams provide personalized, compassionate, expert care to patients of all ages. Informed by basic research done at our Sloan Kettering Institute, scientists across MSK collaborate to conduct innovative translational and clinical research that is driving a revolution in our understanding of cancer as a disease and improving the ability to prevent, diagnose, and treat it. MSK is dedicated to training the next generation of scientists and clinicians, who go on to pursueour missionat MSK and around the globe.

Exciting Opportunity at MSK: Case Manager, Patient Financial Services, Appeals

Memorial Sloan Kettering Cancer Center (MSK) is a world-renowned leader in cancer care, research, and innovation. The Case Manager, Patient Financial Services role is a clinically focused, insurance-based position that helps patients access medically necessary treatment by navigating complex payer requirements, reviewing medical necessity, managing appeals and denials, and serving as a key liaison between patients, providers, and insurance companies.

Role Overview

• Review medical records, clinical documentation, and treatment plans to assess medical necessity and support authorization /appeals requests.
• Facilitate insurance appeals and denial management activities, including preparation of supporting clinical documentation.
• Apply Medicare, Medicaid, and payer-specific guidelines when evaluating coverage and medical necessity criteria.
• Collaborate with physicians and care teams to obtain letters of medical necessity and other supporting documentation.
• Communicate with patients, providers, pharmacies, pharmacy benefit managers (PBMs), and insurance representatives regarding authorization status, appeals, coverage determinations, and benefit information.
• Document case activity, authorization outcomes, payer communications, and appeal strategies in accordance with departmental standards.
• Serve as a liaison between patients, clinical teams, and payers to help ensure timely access to treatment.
• Research and interpret payer policies, coverage requirements, clinical guidelines, and supporting medical literature to strengthen appeals.
• Manage a high-volume caseload while tracking deadlines, prioritizing urgent cases, and ensuring compliance with regulatory requirements.

Key Qualifications

• Bachelor’s degree in Nursing.
• Actively holds NY RN license.
• Clinical nursing experience with strong knowledge of healthcare delivery and patient care.
• Experience with utilization management, utilization review, appeals, denials management, or prior authorization processes.
• Strong background of Medicare regulations and appeal process, Medicaid, and commercial payer coverage guidelines.
• Understanding of state and federal regulations governing health insurance coverage and reimbursement.
• Knowledge of InterQual and Milliman criteria, state and federal healthcare regulations, medical necessity review standards, FDA-approved indications, and pharmacy coverage determination processes.

Core Skills

• Strong chart review and medical necessity assessment skills.
• Ability to interpret and apply Medicare, Medicaid, and payer-specific coverage criteria.
• Excellent written and verbal communication skills (over the phone), particularly in patient and payer interactions.
• Strong critical thinking, problem-solving, and negotiation abilities in complex insurance situations.
• Effective case management and organizational skills with the ability to manage competing priorities, monitor appeal deadlines, and coordinate across clinical, payer, pharmacy, and patient stakeholders.
• Expertise in pharmacy and medication coverage reviews, including formulary analysis, step-therapy exceptions, non-formulary medication appeals, specialty pharmacy services, prior authorization requirements, and payer-specific pharmacy policies.
• High attention to detail, regulatory compliance, professional advocacy, and proficiency with electronic health records, payer portals, prior authorization systems, and Microsoft Office applications.

Additional Information

• Schedule: Monday – Friday from 9:00 AM to 5:00 PM
• Location: Hybrid on-site once a month but more frequently if needed. When in office: 633 Third Avenue, New York, NY
• Reports To: Associate Clinical Director, Patient Financial Services
• FSLA Status: Exempt

Helpful Links

• Compensation Philosophy
• Benefits

Pay Range: $125,400.00 - $200,700.00

Closing

At MSK, we believe in fair, competitive pay that reflects your job, experience, and skills.

MSK is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sexual orientation, national origin, age, religion, creed, disability, veteran status or any other factor which cannot lawfully be used as a basis for an employment decision.

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.