Utilisation Management Leader - RN

Job Description

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: View email address on ziprecruiter.com

PS: Our team reviews applications daily. Please complete your AI interview and application steps to be considered for this opportunity.