Utilization Specialist, Case Management

Memorial Sloan Kettering Cancer Center•New York, NY

3d•$77,100 - $119,400•Hybrid

About The Position

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. If you are passionate about improving outcomes, navigating complex healthcare systems, and making a significant impact on the patient experience, we encourage you to apply!

Requirements

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.
Knowledge of state and federal regulations governing health insurance coverage and utilization management.
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 escalate 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.

Nice To Haves

InterQual or MCG Certification 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.