Utilisation Management and Case Management Leader

Role Overview

Help evaluate and improve AI tools that support clinical review, medical-necessity decisions, and care-coordination workflows. This role is suited to experienced utilization management and case management leaders, including RN UM directors, case management managers, and physician advisors, whose clinical and operational expertise can help advance utilization performance, reduce unnecessary care, and support value-based care goals.

Key Responsibilities

• Lead utilization management and/or case management operations, including concurrent and retrospective review, discharge planning, and care coordination.
• Assess AI-generated medical-necessity determinations, clinical review outputs, and UM decision-support recommendations for accuracy and clinical appropriateness.
• Conduct and oversee clinical reviews using InterQual, MCG, or Milliman guidelines for admission, continued-stay, and level-of-care decisions.
• Manage physician advisor programs for complex UM cases, peer-to-peer review requests, and denial appeals.
• Coordinate with clinical teams, payers, and post-acute providers to support appropriate care transitions and discharge planning.
• Track UM and CM performance measures, including avoidable days, denial rates, observation-to-inpatient conversion rates, and readmission rates.
• Maintain compliance with CMS Conditions of Participation, the Two-Midnight Rule, and payer-specific UM requirements.
• Partner with revenue cycle, compliance, and clinical leaders to align UM performance with financial and quality goals.
• Annotate AI outputs and provide structured clinical feedback for AI training datasets.

Qualifications

• At least 5 years of utilization management, case management, or clinical review experience, including at least 2 years in a leadership role.
• Active clinical license, with RN required. Physician advisor or MD experience is preferred.
• Strong expertise in medical-necessity review and InterQual, MCG, or Milliman clinical review criteria.
• Knowledge of the CMS Two-Midnight Rule, observation-status regulations, and inpatient criteria.
• Experience managing physician advisor programs and payer peer-to-peer review processes.
• Exceptional written and spoken English communication skills.
• Close attention to detail and the ability to critically assess clinical documentation and AI-generated UM outputs.

Preferred Qualifications

• CPUR, ACM, or CCM certification.
• MD or DO credentials with UM or physician advisor experience for physician advisor roles.
• Experience with UM software platforms, including Allscripts or equivalent tools.
• Familiarity with AI tools and comfort evaluating AI-generated clinical review content.
• Experience in health system, ACO, or value-based care organization UM programs.

Work Terms

• Remote, hourly engagement.

Compensation

• $100 to $150 per hour.

Opportunity

• Contribute to advanced healthcare AI systems and clinical decision-support workflows with a focus on utilization management.
• Work with an AI research organization on high-impact healthcare technology initiatives.