Remote Case Management Leader (RN/Physician Advisor)

mercor; United States; A distancia; USD 138.000 - 207.000; A tiempo parcial

Descripción de la vacante

Mercor seeks a leader in utilisation management and case management to guide clinical review operations in a remote contract role. You will coordinate with clinical teams, payers, and AI-enabled processes to ensure appropriate care decisions.

The position requires active RN licensure (MD/DO preferred) with 5+ years in UM or case management, including leadership experience, and deep knowledge of InterQual, MCG, or Milliman criteria. Strong written and verbal English skills are essential.

Formación

• Active clinical licensure (RN required; MD/DO preferred).
• 5+ years in utilisation management or case management or clinical review.
• At least 2 years in a leadership role.
• Deep knowledge of InterQual, MCG, or Milliman criteria.
• Familiar with CMS Two-Midnight Rule and inpatient criteria.
• Excellent written and verbal English communication.

Responsabilidades

• 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.

Conocimientos

Leadership in UM

Clinical review

Communication skills

Detail-oriented

English proficiency

Educación

RN licensure

MD/DO preferred

Herramientas

Allscripts UM

Utilisation Management software

Descripción del empleo

Mercor seeks a leader in utilisation management and case management to guide clinical review operations in a remote contract role. You will coordinate with clinical teams, payers, and AI-enabled processes to ensure appropriate care decisions.

The position requires active RN licensure (MD/DO preferred) with 5+ years in UM or case management, including leadership experience, and deep knowledge of InterQual, MCG, or Milliman criteria. Strong written and verbal English skills are essential.