Exciting Opportunity at MSK: Case Manager, Patient Financial Services, AppealsMemorial Sloan Kettering Cancer Center (MSK) is a world-renowned leader in cancer care, research, and innovation. The Case Manager, Patient Financial Services role is a clinically focused, insurance-based position that helps patients access medically necessary treatment by navigating complex payer requirements, reviewing medical necessity, managing appeals and denials, and serving as a key liaison between patients, providers, and insurance companies.
Role Overview:- Review medical records, clinical documentation, and treatment plans to assess medical necessity and support authorization /appeals requests.
- Facilitate insurance appeals and denial management activities, including preparation of 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 (PBMs), and insurance representatives regarding 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 while tracking deadlines, prioritizing urgent cases, and ensuring compliance with regulatory requirements.
Key Qualifications:- Bachelor's degree in Nursing.
- Actively holds NY RN license.
- Clinical nursing experience with strong knowledge of healthcare delivery and patient care.
- Experience with utilization management, utilization review, appeals, denials management, or prior authorization processes.
- Strong background of Medicare regulations and appeal process, 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.
Core Skills:- 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 (over the phone), particularly in patient and payer interactions.
- Strong critical thinking, problem-solving, and negotiation abilities in complex insurance situations.
- Effective case management and organizational skills with the ability to manage competing priorities, monitor appeal deadlines, and coordinate 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, professional advocacy, and proficiency with electronic health records, payer portals, prior authorization systems, and Microsoft Office applications.
Additional Information:- Schedule: Monday - Friday from 9:00 AM to 5:00 PM
- Location: Hybrid on-site once a month but more frequently if needed. When in office: 633 Third Avenue, New York, NY
- Reports To: Associate Clinical Director, Patient Financial Services
Helpful Links:- Compensation Philosophy
- Benefits
Pay Range: $125,400.00 - $200,700.00
FSLA Status: Exempt
