Case Management Expert - Fully Remote | Upto $150/hr

mercor; United States; Remote; USD 138,000 - 207,000; Part time

Job summary

Mercor connects elite creative and technical talent with leading AI research labs. A remote Utilisation Management leader role is available, requiring RN licensure and physician-advisor experience.

Contract position with high-level responsibility and collaboration across payers and clinical teams. The role emphasizes overseeing concurrent and retrospective reviews, discharge planning, and AI-enabled decision-support validation, with strong English communication skills and meticulous attention to

Qualifications

• 5+ years 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).
• Deep knowledge of InterQual, MCG, or Milliman clinical review criteria.
• Expertise in CMS Two-Midnight Rule, observation status regulations, and inpatient criteria.

Responsibilities

• Lead utilisation management and case management operations, including concurrent and retrospective reviews, discharge planning, and care coordination.
• Evaluate AI-generated medical necessity determinations and UM decision-support outputs for accuracy and appropriateness.
• Conduct and oversee clinical reviews against InterQual, MCG, or Milliman guidelines to support admission and level-of-care determinations.
• Manage the physician advisor program to support complex UM cases, peer-to-peer reviews, and denial appeals.
• Coordinate with clinical teams, payers, and post-acute providers to facilitate care transitions and discharge planning.
• Annotate AI outputs and provide structured clinical feedback to support AI training datasets.

Skills

Leadership

Clinical review

English communication

AI evaluation

Attention to detail

Education

Registered Nurse (RN) licensure

Tools

Allscripts

Utilisation Management software

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

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.