Utilization Specialist, Case Management
About The Position
Memorial Sloan Kettering Cancer Center is seeking a Utilization Specialist to join its Case Management team. The role helps ensure appropriate utilization of healthcare resources and supports high-quality, patient-centered care by applying clinical expertise in a complex healthcare setting. The specialist conducts admission, concurrent, retrospective, and Medicare reviews to determine medical necessity and support appropriate levels of care. The role collaborates with Case Managers, providers, and insurance companies on treatment plans, authorization reviews, denial prevention, and discharge planning. It also involves documenting clinical reviews and related case management activities, maintaining records and databases, identifying quality concerns, and participating in process improvement and departmental initiatives. The position is based at 1275 York Avenue in New York, NY, and is hybrid. Employees may participate in MSK’s hybrid work program after successfully completing a six-month probationary period, subject to departmental guidelines. The schedule is 8:00 a.m. to 4:00 p.m., Monday through Friday. The listed pay range is $77,100 to $119,400.
Requirements
- Current, active state license as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
- At least 2 years of Utilization Review and/or Case Management experience within a healthcare system or insurance organization.
- Knowledge of state and federal regulations governing health insurance coverage and utilization management.
- Strong communication skills and ability to collaborate with interdisciplinary teams, insurance payers, and other stakeholders.
- Sound clinical judgment and ability to analyze clinical information, make utilization review decisions, and escalate concerns as appropriate.
- Strong attention to detail in medical record reviews, documentation, and data entry.
- Excellent organizational and time management skills, including the ability to prioritize competing priorities and maintain accurate, timely documentation.
Nice To Haves
- Knowledge of InterQual software and/or MCG Medical Necessity criteria software.
- InterQual or MCG certification is highly preferred.
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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
