AI-Driven Case Management Leader

Mercor; Houston (TX); On-site; USD 120,000 - 180,000; Full time

Job summary

Mercor partnered with a leading AI research lab to advance utilization management and clinical review for value-based care. The role seeks experienced RN UM directors, case management leaders, and physician advisors to shape AI-enabled decision support and care coordination workflows.

You will lead UM/CM operations, evaluate AI outputs against guidelines, mentor physician advisors, and ensure CMS and payer requirements are met while driving KPI improvements.

Qualifications

• 5+ years in utilisation management, case management, or clinical review with at least 2 years in a leadership role.
• Active RN licensure; physician advisor/MD preferred for certain roles.
• Deep knowledge of InterQual, MCG, or Milliman criteria.
• Excellent written and verbal English communication; strong attention to detail.

Responsibilities

• Lead utilisation management and/or case management operations, including concurrent and retrospective reviews.
• Evaluate AI-generated medical necessity determinations and UM outputs for accuracy and clinical relevance.
• Conduct and oversee reviews against InterQual, MCG, or Milliman guidelines for admission, stay, and level-of-care decisions.
• Manage the physician advisor program to support complex UM cases and peer-to-peer review requests.
• Coordinate with clinical teams, payers, and post-acute providers to facilitate care transitions.
• Monitor UM/CM KPIs such as avoidable days, denial rates, and readmission rates.
• Ensure CMS Participation requirements and payer-specific UM rules are met.
• Collaborate with revenue cycle and leadership to align UM performance with financial and quality objectives.
• Annotate AI outputs and provide structured clinical feedback for AI training datasets.

Skills

Clinical leadership

Clinical review

English communication

Data-driven decisions

Education

RN license

MD/DO preferred

Tools

InterQual

MCG

Milliman

Utilisation software

Job description

Mercor partnered with a leading AI research lab to advance utilization management and clinical review for value-based care. The role seeks experienced RN UM directors, case management leaders, and physician advisors to shape AI-enabled decision support and care coordination workflows.

You will lead UM/CM operations, evaluate AI outputs against guidelines, mentor physician advisors, and ensure CMS and payer requirements are met while driving KPI improvements.