Utilisation Management Expert - RN

Mercor is working with a leading AI research lab to improve the capabilities of next-generation AI systems. We are seeking experienced Utilisation Management and Case Management leaders — including RN UM directors, case management managers, and physician advisors — to evaluate AI tools designed to enhance clinical review, medical-necessity determination, and care-coordination workflows. Your clinical and operational expertise will directly shape AI systems that improve utilisation performance, reduce unnecessary care, and support value-based care objectives. Responsibilities Lead utilisation management and/or 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. Monitor UM/CM KPIs, including avoidable days, denial rates, observation vs. inpatient conversion rates, and readmission rates. Ensure compliance with CMS Conditions of Participation, Two-Midnight Rule, and payer-specific UM requirements. Collaborate with revenue cycle, compliance, and clinical leadership to align UM performance with financial and quality objectives. Annotate AI outputs and provide structured clinical feedback to support AI training datasets. Requirements 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 Qualifications 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. Why Join? Contribute to the development of frontier AI systems in healthcare. Collaborate with a world‑class AI research organisation. Gain exposure to cutting‑edge AI workflows in utilisation management and clinical decision‑support. Opportunity to work on high‑impact projects shaping the future of healthcare AI. #J-18808-Ljbffr Mercor