Utilization Specialist, Case Management

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 pursue our mission at 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. 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!

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.