Utilization Specialist, Case Management

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.

Core Skills

• 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.

Additional Information

Location: 1275 York Avenue, New York, NY. This is a hybrid role. Following successful completion of a six-month probationary period, employees will be eligible to participate in MSK's hybrid work program in accordance with departmental guidelines.

Schedule: 8am-4pm; Monday through Friday.

Pay

Pay Range: $77,100.00 - $119,400.00