UM/CM Leader (RN or Physician Advisor) at Mercor

UM/CM Leader (RN / Physician Advisor) | $100–150/hr | Worldwide Remote

Mercor is partnering with a leading AI research lab to recruit experienced Utilisation Management and Case Management leaders — including RN UM directors, case management managers, and physician advisors — to evaluate and improve AI tools designed for clinical review, medical-necessity determination, and care-coordination workflows. Your expertise will directly shape next-generation AI systems that drive utilisation performance and support value-based care.

Key Responsibilities

• Lead UM and/or CM 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 clinical reviews using InterQual, MCG, or Milliman guidelines to support admission, continued stay, and level-of-care decisions.
• Manage physician advisor programs, peer-to-peer review requests, and denial appeals.
• Coordinate with clinical teams, payers, and post-acute providers to facilitate appropriate care transitions.
• Monitor UM/CM KPIs including avoidable days, denial rates, observation vs. inpatient conversion, and readmission rates.
• Ensure compliance with CMS Conditions of Participation, the Two-Midnight Rule, and payer-specific UM requirements.
• Collaborate with revenue cycle, compliance, and clinical leadership to align UM performance with financial and quality goals.
• Annotate AI outputs and provide structured clinical feedback to support AI training datasets.

Requirements

• 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; MD/physician advisor preferred).
• 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 payer peer-to-peer review processes.
• Exceptional written and verbal English communication skills with strong attention to detail.

Preferred Qualifications

• CPUR, ACM, or CCM certification.
• MD or DO with UM/physician advisor experience (for physician advisor roles).
• Experience with UM software platforms such as Allscripts or equivalent.
• Familiarity with AI tools and comfort evaluating AI-generated clinical content.
• Background in health system, ACO, or value-based care UM programs.

Why Join?

• Contribute to frontier AI development in healthcare.
• Collaborate with a world-class AI research organisation.
• Gain exposure to cutting-edge AI workflows in utilisation management and clinical decision-support.
• Work on high-impact projects shaping the future of healthcare AI.