Full-Time
Utilization and Appeals Manager
Updated on 9/10/2026
Deadline 5/19/27
Catholic Health
Long Island health system
Compensation Overview
$110k - $150k/yr
Melville, NY, USA
In Person
Bachelor's
Category
 Medical, Clinical & Veterinary |
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Required Skills
Epic (EHR)
Financial analysis
Requirements
- Graduation from an accredited nursing school or college.
- A current New York State Registered Nurse license is required.
- At least 5 years of relevant medical-surgical or specialty clinical experience is required.
- Experience writing appeals and experience in care management in an acute hospital or related managed care setting are required.
- Ongoing education, certification, and self-development are required to remain current with industry standards and business objectives related to utilization and care management.
- Knowledge and skill in using personal computers and software for word processing and spreadsheets are required.
- Experience with EPIC, Midas, Star, and other hospital software is required as applicable.
- Ability to communicate effectively with all levels of hospital staff verbally and in writing.
- Ability to organize, prioritize, and manage assignments efficiently with minimal oversight and direction.
- Ability to work courteously and collaboratively with hospital staff and other health team members.
- Ability to seek clinical expertise or references for specialty services when preparing clinical reviews or appeals.
- Aptitude for applying financial and reimbursement principles to utilization and appeal functions and reporting.
- Ability to use critical thinking and sound clinical judgment and assessment skills for decision-making.
- Expert knowledge of evidence-based guidelines applicable to utilization and appeals.
- Knowledge of requirements from third-party payers, regulatory agencies, and managed care entities concerning levels of care, continuity of benefits, and medical necessity guidelines.
- Knowledge of managed care and current standards and trends in patient care, best practices, and management tools.
- Maintaining patient confidentiality and the security of electronic information in compliance with department, hospital, Peer Review Organization, and New York State regulations and policies.
Responsibilities
- Conduct clinical reviews and appeals according to accepted clinical-criteria guidelines.
- Receive, manage, and provide clinical reviews or submissions required by contractual or regulatory requirements.
- Research initial denials, identify denial reasons and contributing factors, and mitigate, manage, or escalate denials when appropriate.
- Submit initial reviews, appeal reviews, and letters within contractual or regulatory timeframes.
- Collaborate in clinical discussions with the Catholic Health Physician Advisor when appropriate.
- Review determinations from managed care payors and regulatory agencies and take further action as needed.
- Manage and follow up on certification and appeal status with managed care payors or regulatory agencies.
- Respond to payor queries for additional clinical documentation.
- Act as a liaison between the Utilization and Appeals Management Department and physicians of record.
- Communicate changes to patient status and level of care to MCC in response to physician orders or updated clinical information.
- Provide guidance to MCC and Care Management regarding regulatory or managed care requirements.
- Identify managed care, regulatory, and compliance issues contributing to denial activity and report findings to department leadership.
- Complete data-tracking tools and participate in required meetings and committees.
- Provide information, guidance, and support to the administrative support team.
- Serve as a liaison for intra- and interdepartmental communications.
- Apply third-party contractual changes to utilization management and appeals-management processes.
- Work collaboratively with physicians, physician office staff, and other health team members on payer and contract issues and appeal preparation.
Desired Qualifications
- A Bachelor of Science in Nursing degree is preferred.
- Knowledge of Federal, State, and Peer Review Organization regulations is preferred.
Catholic Health is a Catholic nonprofit health system serving Long Island. The organization operates hospitals, physician practices, ambulatory sites, home care, hospice, rehabilitation, and specialty programs. It serves patients, families, clinicians, referring providers, and communities across Nassau and Suffolk counties. Its operating model centers on mission-based care delivered through hospitals and community settings with shared clinical, technology, and administrative support. Teams work across nursing, physicians, allied health, home care, rehabilitation, technology, facilities, administration, and patient services. Teams support coordinated daily delivery.
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