Utilization Review And Appeals Case Manager

Position Summary

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 of a Utilization Review and Appeals Case Manager may include the following but are not limited to:

• 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.

Please Note: Verification of degree (e.g., diploma or official transcript) is required for this role. Upload of documentation must be included with your application for consideration.

Special Notes: Resume/CV should be included with the online application.

Posting Overview: This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date).

If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and possibly reposted at a later date.

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• Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions maybe subject to changes in pass days and shifts as necessary.
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
• This function/position maybe designated as "essential." This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.

Prior to start date, the selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services*
• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4 panel drug screen*
• Meet Regulatory Requirements for pre employment screenings.
• Provide a copy of any required New York State license(s)/certificate(s).

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

• The hiring department will be responsible for any fee incurred for examination.

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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 (631)632-6280.

In accordance with the Title II Crime Awareness and Security Act a copy of our crime statistics can be viewed here.

Visit our WHY WORK HERE page to learn about the total rewards we offer.

Stony Brook University Hospital, consistent with our shared core values and our intent to achieve excellence, remains dedicated to supporting healthier and more resilient communities, both locally and globally.

Anticipated Pay Range:

The salary range (or hiring range) for this position is $89,760 - $127,975 Base

The above salary range represents SBUH's good faith and reasonable estimate of the range of possible compensation at the time of posting. The specific salary offer will be based on the candidate's validated years of comparable experience. Any efforts to inflate or misrepresent experience are grounds for disqualification from the application process or termination of employment if hired.

Some positions offer annual supplemental pay such as:

• Location pay for UUP, CSEA & PEF full-time positions ($4000)

Your total compensation goes beyond the number in your paycheck. SBUH provides generous leave, health plans, and a state pension that add to your bottom line.

Visit our WHY WORK HERE page to learn about the total rewards we offer.

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