Himalayas
clinical reviewcase managementcase management professionalutilization reviewhealthcare case managerremote case managerremote case managementutilisation management
Job Description
About the job
Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.
Position: Utilisation Management / Case Management leader (RN/Physician-advisor)
Type:Contract
Compensation:$100–$150/hour
Location:Remote
Role Responsibilities
- Lead utilisation management and case management operations, including concurrent review, retrospective review, discharge planning, and care coordination.
- Evaluate AI-generated medical necessity determinations, clinical review outputs, and UM decision-support recommendations for accuracy and clinical appropriateness.
- Conduct and oversee clinical reviews against InterQual, MCG, or Milliman care guidelines to support admission, continued stay, and level-of-care determinations.
- Manage the physician advisor program to support complex UM cases, peer-to-peer review requests, and denial appeals.
- Coordinate with clinical teams, payers, and post-acute providers to facilitate appropriate care transitions and discharge planning.
- Annotate AI outputs and provide structured clinical feedback to support AI training datasets.
Qualifications
Must-Have
- 5+ years of experience in utilisation management, case management, or clinical review, with at least 2 years in a leadership role.
- Active clinical licensure (RN required; physician advisor/MD preferred) with strong medical necessity review expertise.
- Deep knowledge of InterQual, MCG, or Milliman clinical review criteria.
- Expertise in CMS Two-Midnight Rule, observation status regulations, and inpatient criteria.
- Experience managing physician advisor programs and peer-to-peer review processes with payers.
- Exceptional written and verbal English communication skills.
- High attention to detail with the ability to critically evaluate clinical documentation and AI-generated UM outputs.
Preferred
- CPUR (Certified Professional in Utilisation Review), ACM (Accredited Case Manager), or CCM (Certified Case Manager) credential.
- MD or DO with UM/physician advisor experience preferred for physician advisor roles.
- Experience with UM software platforms (Allscripts, Utilisation Management software, or equivalent).
- Familiarity with AI tools and comfort evaluating AI-generated clinical review content.
- Background in health system, ACO, or value-based care organisation UM programs.
Application Process (Takes 20–30 mins to complete)
- Upload resume
- AI interview based on your resume
- Submit form
Resources & Support
- For details about the interview process and platform information, please check:
- For any help or support, reach out to:
PS: Our team reviews applications daily. Please complete your AI interview and application steps to be considered for this opportunity.
Originally posted on Himalayas
