RN Case Manager, Patient Financial 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

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.