Role Overview
This role evaluates and shapes AI tools that support clinical review, medical necessity determinations, and care coordination for utilisation management and case management. You will apply clinical and operational expertise to assess AI-generated review outputs, align decisions to established criteria, and provide structured feedback that improves AI performance and supports value-based care goals.
Key Responsibilities- Lead utilisation management and case management activities, including concurrent review, retrospective review, discharge planning, and care coordination.
- Evaluate AI-generated medical necessity determinations, clinical review outputs, and decision-support recommendations for accuracy and clinical appropriateness.
- Conduct and oversee clinical reviews using InterQual, MCG, or Milliman guidelines to support admission, continued stay, and level-of-care decisions.
- 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 and CM performance indicators, including avoidable days, denial rates, observation versus inpatient conversion rates, and readmission rates.
- Ensure compliance with CMS Conditions of Participation, the Two-Midnight Rule, and payer-specific utilisation management 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.
Required
- At least 5 years of experience in utilisation management, case management, or clinical review, including a minimum of 2 years in a leadership role.
- Active clinical licensure, RN required. Physician advisor roles, MD or DO, are preferred.
- Deep working knowledge of InterQual, MCG, or Milliman clinical review criteria.
- Expertise with CMS Two-Midnight Rule, observation status regulations, and inpatient criteria.
- Experience managing physician advisor programs and payer peer-to-peer review processes, including denial appeals.
- Exceptional written and verbal English communication skills.
- High attention to detail and the ability to critically evaluate clinical documentation and AI-generated UM outputs.
Preferred
- CPUR, ACM, or CCM certification.
- MD or DO with prior UM or physician advisor experience for physician advisor roles.
- Experience with UM software platforms such as Allscripts or equivalent utilisation management systems.
- Familiarity with AI tools and comfort evaluating AI-generated clinical review content.
- Background working in a health system, ACO, or value-based care organisation UM program.
- Location: Remote
- Employment Type: Hourly
- Hourly rate: 100 - 150 per hour
- Active clinical licensure required, RN for clinical reviewer roles; MD or DO preferred for physician advisor positions.
- Strong English language proficiency, written and verbal.
- Contribute clinical expertise to the development of advanced AI systems for healthcare.
- Collaborate with a leading AI research organization on high-impact projects.
- Gain exposure to cutting-edge AI workflows in utilisation management and clinical decision support.