Utilisation Management & Case Management Leader (RN / Physician Advisor)

Role Overview

Mercor is partnering with a leading AI research laboratory to improve next-generation AI systems focused on utilisation management, clinical review, and care coordination decision-support.

This role is designed for experienced Utilisation Management (UM) and Case Management leaders — including RN UM Directors, Case Management Managers, and Physician Advisors — who bring deep expertise in medical necessity review, clinical guidelines, and care-level decision-making.

You will evaluate AI-generated utilisation management recommendations, clinical review outputs, and decision-support tools to ensure clinical accuracy, guideline adherence, and real-world applicability across hospital and payer environments.

Responsibilities

Utilisation Management & Case Management Leadership

• Lead end-to-end UM/CM operations including concurrent review, retrospective review, admission and continued stay reviews, and discharge planning
• Oversee clinical decision-making workflows supporting appropriate level-of-care determinations

Clinical Review & Medical Necessity Evaluation

• Evaluate AI-generated outputs including medical necessity determinations, clinical review summaries, and utilisation decision-support recommendations
• Review clinical documentation against established criteria: InterQual, MCG, Milliman guidelines
• Ensure accuracy, appropriateness, and compliance with clinical standards

Physician Advisor Program Management

• Manage physician advisor workflows for complex UM cases
• Coordinate peer-to-peer review processes with payers
• Support clinical escalation and appeal pathways for denied cases

Care Coordination & Transitions

• Coordinate with clinical teams, payers, and post-acute care providers
• Ensure appropriate discharge planning and care transitions
• Reduce avoidable days and unnecessary utilisation

Performance Monitoring

Track and improve UM/CM KPIs including avoidable days, denial rates, observation vs inpatient conversion rates, readmission rates, and length of stay efficiency.

Regulatory & Compliance Oversight

Ensure adherence to CMS Conditions of Participation, Two-Midnight Rule, observation status regulations, and payer-specific UM policies.

AI Evaluation & Annotation

• Evaluate AI-generated clinical review outputs for clinical accuracy, guideline adherence, decision appropriateness, and documentation completeness
• Provide structured feedback to improve AI training datasets

Requirements

Clinical Experience

• 5+ years in utilisation management, case management, or clinical review
• At least 2 years in a leadership role
• Active clinical licensure required: RN (minimum); MD/DO preferred for physician advisor roles

Clinical Knowledge

• InterQual criteria, MCG guidelines, Milliman care guidelines
• Medical necessity determination
• Inpatient vs observation level-of-care decisions

Regulatory Knowledge

• CMS Two-Midnight Rule
• Observation status regulations
• Utilisation management compliance requirements
• Payer UM policies

Operational Expertise

• Physician advisor program management
• Peer-to-peer review coordination
• Care transition and discharge planning
• Hospital or health system UM workflows

Preferred Qualifications

• CPUR, ACM, or CCM certification
• Experience in ACOs, value-based care, or integrated delivery systems
• Physician advisor experience (MD/DO roles strongly preferred)
• Familiarity with UM software platforms (e.g., Allscripts or equivalent)
• Experience evaluating AI-assisted clinical decision-support tools

Contract & Payment Terms

• Independent contractor role
• Fully remote work environment
• Flexible scheduling
• Weekly payments via Stripe or Wise

Important Notice

Mercor does not support H1-B visa sponsorship or STEM OPT candidates.

About Mercor

Mercor partners with leading AI research organisations and healthcare enterprises to build advanced AI systems using domain experts in clinical operations and utilisation management.