Case Management Leader - Fully Remote | Upto $150/hr
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 and clinical review outputs for accuracy and clinical appropriateness.
- Conduct and oversee clinical reviews against InterQual , MCG , or Milliman care guidelines to support admission 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 , ACM , or CCM 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.
Resources & Support
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PS: Our team reviews applications daily. Please complete your AI interview and application steps to be considered for this opportunity.
Originally posted on Himalayas