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

$100–150/hr

25 people hired

RemoteGlobalTechnology3-5 YearsContractPosted Aug 20, 2026

About this role

You will evaluate AI tools supporting utilisation management, medical-necessity review, case management, and clinical decision-support. | The role covers concurrent and retrospective review, discharge planning, care coordination, and level-of-care determinations. | You will assess AI-generated clinical recommendations using InterQual, MCG, Milliman, and regulatory standards. | Your expertise will help improve AI systems supporting healthcare utilisation and value-based care.

Responsibilities

Evaluate AI-generated medical-necessity determinations, clinical reviews, and UM decision-support recommendations for accuracy and appropriateness.
Review cases using InterQual, MCG, or Milliman criteria and support admission, continued-stay, observation, and level-of-care decisions.
Support physician-advisor programs, peer-to-peer reviews, denial appeals, discharge planning, and care coordination.
Monitor UM/CM performance and provide structured clinical feedback for AI training datasets.

Qualifications

Minimum 5+ years of experience in utilisation management, case management, or clinical review, including 2+ years in leadership.
Active clinical licensure required, with RN required for nursing roles and MD/physician experience preferred for physician-advisor roles.
Deep knowledge of InterQual, MCG, or Milliman criteria, CMS Two-Midnight Rule, observation status, and inpatient requirements.
Experience with physician-advisor programs, payer peer-to-peer reviews, clinical documentation, and medical-necessity evaluation.