Description
Mercor is working with a leading AI research lab to improve the capabilities of next-generation AI systems. We are seeking experienced Utilisation Management and Case Management leaders — including RN UM directors, case management managers, and physician advisors — to evaluate AI tools designed to enhance clinical review, medical-necessity determination, and care-coordination workflows. Your clinical and operational expertise will directly shape AI systems that improve utilisation performance, reduce unnecessary care, and support value-based care objectives.
Responsibilities
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Lead utilisation management and/or case management operations, including concurrent review, retrospective review, discharge planning, and care coordination.
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Evaluate AI-generated medical necessity determinations, clinical review outputs, and UM decision-support recommendations for accuracy and clinical appropriateness.
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Conduct and oversee clinical reviews against InterQual, MCG, or Milliman care guidelines to support admission, continued stay, and level-of-care determinations.
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Manage the physician advisor program to support complex UM cases, peer-to-peer review requests, and denial appeals.
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Coordinate with clinical teams, payers, and post-acute providers to facilitate appropriate care transitions and discharge planning.
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Monitor UM/CM KPIs, including avoidable days, denial rates, observation vs. inpatient conversion rates, and readmission rates.
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Ensure compliance with CMS Conditions of Participation, Two-Midnight Rule, and payer-specific UM requirements.
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Collaborate with revenue cycle, compliance, and clinical leadership to align UM performance with financial and quality objectives.
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Annotate AI outputs and provide structured clinical feedback to support AI training datasets.
Requirements
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5+ years of experience in utilisation management, case management, or clinical review, with at least 2 years in a leadership role.
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Active clinical licensure (RN required; physician advisor/MD preferred) with strong medical necessity review expertise.
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Deep knowledge of InterQual, MCG, or Milliman clinical review criteria.
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Expertise in CMS Two-Midnight Rule, observation status regulations, and inpatient criteria.
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Experience managing physician advisor programs and peer-to-peer review processes with payers.
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Exceptional written and verbal English communication skills.
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High attention to detail with the ability to critically evaluate clinical documentation and AI-generated UM outputs.
Preferred Qualifications
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CPUR (Certified Professional in Utilisation Review), ACM (Accredited Case Manager), or CCM (Certified Case Manager) credential.
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MD or DO with UM/physician advisor experience preferred for physician advisor roles.
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Experience with UM software platforms (Allscripts, Utilisation Management software, or equivalent).
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Familiarity with AI tools and comfort evaluating AI-generated clinical review content.
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Background in health system, ACO, or value-based care organisation UM programs.
Why Join?
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Contribute to the development of frontier AI systems in healthcare.
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Collaborate with a world-class AI research organisation.
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Gain exposure to cutting-edge AI workflows in utilisation management and clinical decision-support.
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Opportunity to work on high-impact projects shaping the future of healthcare AI.
We consider all qualified applicants without regard to legally protected characteristics and provide reasonable accommodations upon request.
Contract and Payment Terms
- You will be engaged as an independent contractor.
- This is a fully remote role that can be completed on your own schedule.
- Projects can be extended, shortened, or concluded early depending on needs and performance.
- Your work at Mercor will not involve access to confidential or proprietary information from any employer, client, or institution.
- Payments are weekly on Stripe or Wise based on services rendered.
- Please note: We are unable to support H1-B or STEM OPT candidates at this time.
