Utilization Specialist, Case Management

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

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: Memorial Sloan Kettering Cancer Center (MSK) is seeking a Utilization Specialist to join our Case Management team. In this role, you will help ensure appropriate utilization of healthcare resources, working with interdisciplinary partners to support high-quality, patient-centered care. This is an opportunity to apply your clinical expertise and help support MSK in our mission of ending cancer for life.

Role Overview

• 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.

Key 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 within a healthcare system or insurance organization required.
• Knowledge of InterQual software and/or MCG Medical Necessity criteria software; InterQual or MCG Certification highly preferred Knowledge of state and federal regulations governing health insurance coverage and utilization management.

Core Skills

• Strong communication skills with the ability to collaborate effectively with interdisciplinary teams, insurance payers, and other stakeholders.
• Sound clinical judgment with the ability to analyze clinical information, make utilization review decisions, and elevate concerns as appropriate.
• Strong attention to detail, ensuring accuracy in medical record reviews, documentation, and data entry.
• Excellent organizational and time management skills with the ability to prioritize competing priorities and maintain accurate, timely documentation.

Additional Information

Location: 1275 York Avenue, New York, NY. This is a hybrid role. Following successful completion of a six-month probationary period, employees will be eligible to participate in MSK's hybrid work program in accordance with departmental guidelines.

Schedule: 8am-4pm; Monday through Friday

Helpful Links: MSK Compensation Philosophy Review Our Greats Benefits Offerings

Pay Range: $77,100.00 - $119,400.00

FSLA Status: Exempt

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.

Our multi-disciplinary teams work together to provide exceptional patient care, develop innovative research, and deliver outstanding educational programs.

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