RN Utilization Specialist, Case Management (Hybrid)

Memorial Sloan Kettering Cancer Center; New York (NY); Hybrid; USD 77,000 - 119,000; Full time

Job summary

Memorial Sloan Kettering Cancer Center in New York is seeking a Utilization Specialist to join our Case Management team. The role focuses on admission, concurrent, retrospective, and Medicare reviews to determine medical necessity and ensure appropriate levels of care.

You will collaborate with case managers, providers, and insurers to support treatment plans, authorization reviews, and discharge planning, while documenting in accordance with regulatory requirements.

Qualifications

• Licensed Practical Nurse (LPN) or Registered Nurse (RN) with a current, active state license required.
• Minimum 2 years of Utilization Review and/or Case Management experience.
• Knowledge of InterQual/MCG criteria software; InterQual or MCG Certification preferred.
• Knowledge of state and federal regulations governing health insurance coverage and utilization management.

Responsibilities

• Perform admission, concurrent, retrospective, and Medicare reviews to determine medical necessity and support appropriate levels of care.
• Collaborate with Case Managers, providers, and insurance companies to support treatment plans, authorization reviews, denial prevention, and discharge planning.
• Document clinical reviews, payer communications, treatment delays, avoidable days, and other case management activities in accordance with departmental and regulatory requirements.
• Maintain accurate records and databases, organize clinical information, and support concurrent and retrospective utilization reviews.
• Identify quality concerns, report potential issues, and provide guidance on case management processes and payer requirements.
• Participate in departmental initiatives, process improvement efforts, and ongoing learning to support operational excellence and high-quality patient care.

Skills

Communication

Clinical judgment

Attention to detail

Organization & time management

Education

LPN or RN with active license

Tools

InterQual/MCG software

Job description

Memorial Sloan Kettering Cancer Center in New York is seeking a Utilization Specialist to join our Case Management team. The role focuses on admission, concurrent, retrospective, and Medicare reviews to determine medical necessity and ensure appropriate levels of care.

You will collaborate with case managers, providers, and insurers to support treatment plans, authorization reviews, and discharge planning, while documenting in accordance with regulatory requirements.