Case Management Leader for AI-Driven Clinical Review

Mercor

Houston (TX)

On-site

USD 120,000 - 180,000

Full time

14 days+

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Job summary

Mercor partners with a leading AI research lab to enhance AI-enabled clinical review, medical necessity determinations, and care-coordination workflows. We seek experienced Utilisation Management and Case Management leaders to guide teams, ensure compliance, and drive value-based care outcomes.

You will oversee concurrent and retrospective reviews, discharge planning, physician advisor programs, and collaborations with payers and clinical teams to optimize utilization performance and patient

Qualifications

5+ years in utilisation management or case management with at least 2 years in a leadership role.
Active RN licensure; physician advisor/MD preferred.
Deep knowledge of InterQual, MCG, or Milliman clinical review criteria.
Experience with CMS Two‑Midnight Rule and inpatient criteria.
Strong written and verbal English communication.
Experience managing physician advisor programs and payer interactions.

Responsibilities

Lead utilisation management and/or case management operations (concurrent and retrospective review, discharge planning, care coordination).
Evaluate AI-generated determinations for accuracy and clinical appropriateness.
Oversee clinical reviews against InterQual/MCG/Milliman guidelines for admissions and level-of-care decisions.
Manage physician advisor program to support complex UM cases and denials.
Coordinate with clinical teams, payers, and post-acute providers for appropriate care transitions.
Monitor UM/CM KPIs (avoidable days, denial rates, readmission rates).
Ensure CMS compliance and payer-specific UM requirements.
Collaborate with revenue cycle, compliance, and clinical leadership to align UM with financial and quality goals.
Annotate AI outputs and provide structured feedback for AI training datasets.