Case Manager, Patient Financial Services - Appeals

Memorial Sloan Kettering Cancer Center•New York, NY

1d•Hybrid

About The Position

The Case Manager, Patient Financial Services, Appeals is a clinically focused, insurance-based role that helps patients access medically necessary treatment. The position navigates payer requirements, reviews medical necessity, manages appeals and denials, and serves as a liaison among patients, providers, and insurance companies. The role reviews medical records, clinical documentation, and treatment plans; facilitates insurance appeals and denial management; applies Medicare, Medicaid, and payer-specific guidelines; and coordinates supporting documentation with physicians and care teams. It also communicates with patients, providers, pharmacies, pharmacy benefit managers, and insurers about authorization status, appeals, coverage determinations, and benefits. The Case Manager documents case activity and payer communications, researches payer policies and medical literature, and manages a high-volume caseload while tracking deadlines, prioritizing urgent cases, and complying with regulatory requirements. The schedule is Monday through Friday, 9:00 AM to 5:00 PM. The position is hybrid, with on-site work once a month and more frequently if needed, at 633 Third Avenue, New York, NY.

Requirements

Bachelor’s degree in Nursing.
Active New York RN license.
Clinical nursing experience and strong knowledge of healthcare delivery and patient care.
Experience with utilization management, utilization review, appeals, denials management, or prior authorization processes.
Strong knowledge of Medicare regulations and appeals processes, 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.
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, particularly in patient and payer interactions over the phone.
Strong critical thinking, problem-solving, and negotiation abilities in complex insurance situations.
Effective case management and organizational skills, including managing competing priorities, monitoring appeal deadlines, and coordinating 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, and professional advocacy.
Proficiency with electronic health records, payer portals, prior authorization systems, and Microsoft Office applications.

Responsibilities

Review medical records, clinical documentation, and treatment plans to assess medical necessity and support authorization and appeal requests.
Facilitate insurance appeals and denial management, including preparing 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, and insurance representatives about 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, track deadlines, prioritize urgent cases, and ensure compliance with regulatory requirements.