Utilization Review and Appeals Case Manager

Overview This position is responsible for performing utilization management and concurrent review activities to ensure appropriate level of care determinations for patients receiving inpatient, observation, emergency, and outpatient services. The role includes conducting concurrent and retrospective chart reviews to evaluate medical necessity, support authorization processes, and assist with verbal and written appeals related to denied services or length-of-stay determinations for commercial, government, and external payers. The Utilization Management Registered Nurse collaborates with interdisciplinary care teams, providers, and payers to promote quality, cost-effective patient care while ensuring compliance with regulatory guidelines and payer criteria. Qualified candidates demonstrate strong clinical judgment, exceptional communication and documentation skills, and a commitment to delivering high-quality patient-centered care in a fast-paced healthcare environment. Duties and Responsibilities Conduct utilization review of inpatient, outpatient, and post-acute services to determine medical necessity, appropriateness of care, and compliance with payer guidelines and regulatory standards. Review clinical documentation, treatment plans, laboratory results, and physician notes to support authorization and continued stay determinations. Collaborate with physicians, case managers, social workers, and interdisciplinary care teams to coordinate cost-effective, high-quality patient care. Apply evidence-based criteria such as InterQual or Milliman Care Guidelines (MCG) to evaluate admissions, continued stays, and discharge planning needs. Communicate authorization decisions, denials, and appeals information to providers, patients, and insurance representatives in a timely manner. Monitor patient progress and identify opportunities to improve resource utilization, reduce unnecessary admissions, and prevent delays in care. Facilitate discharge planning and transitions of care to ensure appropriate placement and continuity of services. Maintain accurate and timely documentation of utilization review activities, case notes, and authorization outcomes within electronic medical record systems. Ensure compliance with CMS, Joint Commission, HIPAA, and organizational policies related to utilization management and patient confidentiality. Participate in quality improvement initiatives, audits, and performance monitoring activities related to utilization management outcomes. Educate healthcare staff on payer requirements, medical necessity criteria, and utilization review processes. Analyze trends in denials, appeals, and utilization patterns to support operational improvements and cost-containment strategies. Serve as a liaison between healthcare providers, insurance companies, and patients to resolve authorization and coverage issues. Prioritize and manage a caseload of patients while meeting productivity, turnaround time, and quality metrics. Stay current on healthcare regulations, payer policies, and industry best practices impacting utilization management and case review processes. Other duties as assigned. Qualifications Required Qualifications NY License. Bachelor’s Degree. Three to Five years RN experience in an Acute Care Hospital. Working knowledge of MCG or Interqual. Knowledge of Regulatory agencies and standards of care. Computer Skills in Word, Excel and PowerPoint. Excellent Communication Skills. Creative, flexible, professional and courteous. Weekday and weekend flexibility. Preferred Qualifications Master’s Degree. Experience or Certified in Case Management, Quality, Risk, MCG, CDI or Utilization Management. PRI certified. Demonstrate experience in Appeal and Denial writing. Proficient in Word and Excel and other computer skill sets. Experience with Psychiatry, Pediatrics or Neonatal Care. Coding Experience. Bilingual. EEO and Compliance Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws. If you need a disability-related accommodation, please call the University Office of Equity and Access at View phone number on click.appcast.io. #J-18808-Ljbffr