Utilisation Management / Case Management leader (RN/Physician-advisor)

About this role

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.

Eligible applicant countries

This role accepts applicants from:

• USA

Skills & domains

• ai-training
• rlhf
• sme
• annotation
• Medicine