Case Manager, Patient Financial Services - Appeals

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: Case Manager, Patient Financial Services, Appeals Memorial 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: Pay Range: $125,400.00 - $200,700.00 FSLA Status: FSLA Status: Exempt Closing : At MSK, we believe in fair, competitive pay that reflects your job, experience, and skills. MSK is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sexual orientation, national origin, age, religion, creed, disabil #J-18808-Ljbffr msk