Utilisation Management / Case Management leader (RN/Physician-advisor)

• Lead utilisation management and/or 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.
• Monitor UM/CM KPIs, including avoidable days, denial rates, observation vs. inpatient conversion rates, and readmission rates.
• Ensure compliance with CMS Conditions of Participation, Two-Midnight Rule, and payer-specific UM requirements.
• Collaborate with revenue cycle, compliance, and clinical leadership to align UM performance with financial and quality objectives.
• Annotate AI outputs and provide structured clinical feedback to support AI training datasets.

• 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.

• 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.

Project and contracting process: Mercor. Applications continue on the provider's website.