Case Manager, Patient Financial Services – Appeals

MSK

. Review medical records, clinical documentation, and treatment plans to assess medical necessity and support authorization and appeals requests .

Posted 10/22/2026full-timeNew York City • New York • United StatesMid-LevelSenior💰 $125,400 - $200,700 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical necessity assessment, appeals management, and utilization review, with a strong understanding of Medicare, Medicaid, and payer-specific guidelines. Proficient in case management and effective communication with patients and healthcare providers to facilitate timely access to treatment.

Highest-signal resume keywords

Bachelor's Degree In NursingNY RN LicenseUtilization Management ExperienceMedicare Regulations KnowledgeElectronic Health Records Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity AssessmentUtilization ReviewAppeals ManagementChart ReviewPharmacy Coverage ReviewInterQual Criteria KnowledgeMilliman Criteria KnowledgeRegulatory CompliancePrior Authorization ProcessesCritical Thinking

Soft Skills

Excellent Communication SkillsProblem-Solving AbilitiesNegotiation SkillsOrganizational SkillsAttention To Detail

Tools & Technologies

Electronic Health RecordsPayer PortalsPrior Authorization SystemsMicrosoft Office Applications

Certifications & Qualifications

NY RN License

Industry Keywords

Healthcare DeliveryPatient CareInsurance AppealsDenial ManagementCoverage DeterminationsClinical DocumentationFDA-Approved IndicationsPharmacy Benefit ManagersState And Federal RegulationsFormulary Analysis

About the role

Key responsibilities & impact

Review medical records, clinical documentation, and treatment plans to assess medical necessity and support authorization and 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, 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

Requirements

What you’ll need

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
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