Remote Utilization & Case Management Lead (RN/MD)

Appsierra Group; United States; On-site; USD 138,000 - 207,000; Part time

Benefits offered by this job

Weekly payments

Remote work in US

Flexible schedule

Job summary

Appsierra Group seeks a Utilization Management / Case Management Leader (RN/Physician Advisor) for a remote, hourly-contract role in the United States. You will lead UM/CM operations, oversee physician-advisor programs, and ensure compliance with CMS guidelines while applying AI-enabled reviews to improve efficiency.

Ideal candidates have 5+ years in UM/CM with leadership, active RN licensure (MD/DO preferred), and strong knowledge of InterQual/MCG/Milliman criteria.

Qualifications

• 5+ years in utilization management or case management with leadership exposure.
• Active RN licensure; physician advisor/MD preferred.
• Deep knowledge of InterQual, MCG, or Milliman criteria.
• CMS Two-Midnight Rule and observation/inpatient criteria knowledge.
• Experience managing physician advisor programs with payers.
• Excellent written and verbal English communication.
• Detail-oriented with ability to evaluate AI outputs.

Responsibilities

• Lead utilization management and/or case management operations, including concurrent review, retrospective review, discharge planning, and care coordination.
• Evaluate AI-generated medical necessity determinations and UM decision-support outputs for accuracy.
• Conduct and oversee clinical reviews against InterQual, MCG, or Milliman criteria.
• Manage the physician advisor program to support complex UM cases and appeals.
• Coordinate with clinical teams, payers, and post-acute providers for care transitions.
• Monitor UM/CM KPIs such as avoidable days and readmission rates.
• Ensure CMS and payer-specific UM requirements compliance.
• Collaborate with revenue cycle and clinical leadership to align UM with financial/quality objectives.
• Annotate AI outputs and provide structured clinical feedback for AI training.

Skills

Utilization management

Case management leadership

Clinical review

Stakeholder collaboration

Quality & compliance

Education

RN licensure

Tools

InterQual

MCG

Milliman

Allscripts UM software

Job description

Appsierra Group seeks a Utilization Management / Case Management Leader (RN/Physician Advisor) for a remote, hourly-contract role in the United States. You will lead UM/CM operations, oversee physician-advisor programs, and ensure compliance with CMS guidelines while applying AI-enabled reviews to improve efficiency.

Ideal candidates have 5+ years in UM/CM with leadership, active RN licensure (MD/DO preferred), and strong knowledge of InterQual/MCG/Milliman criteria.