Utilisation Management / Case Management Leader (RN / Physician Advisor)

$100–150/hr

55 people hired

RemoteUSTechnology5-8 YearsContractPosted Aug 13, 2026

About this role

You will support the evaluation and improvement of AI systems designed to enhance utilisation management, case management, clinical review, medical-necessity determination, and care-coordination workflows. The role combines clinical leadership with AI quality evaluation, focusing on concurrent and retrospective review, discharge planning, level-of-care decisions, physician advisory programs, and payer-facing clinical reviews. Your expertise will help ensure AI-generated recommendations are clinically appropriate, compliant, and aligned with utilisation, financial, and value-based care objectives.

Responsibilities

Utilisation management leadership: Lead UM and/or case management operations, including concurrent review, retrospective review, discharge planning, and care coordination.
AI clinical evaluation: Review AI-generated medical necessity determinations, clinical review outputs, and decision-support recommendations for accuracy and clinical appropriateness.
Medical necessity review: Apply InterQual, MCG, Milliman, or equivalent clinical criteria to admission, continued-stay, and level-of-care decisions.
Physician advisor management: Support complex utilisation cases, peer-to-peer reviews, payer discussions, and denial appeals.
Care coordination: Collaborate with clinical teams, payers, and post-acute providers to support appropriate transitions of care and discharge planning.
KPI monitoring: Track avoidable days, denial rates, observation-to-inpatient conversion, readmissions, and other UM/CM performance indicators.
Regulatory compliance: Ensure workflows align with CMS Conditions of Participation, the Two-Midnight Rule, observation status requirements, and payer-specific UM policies.
Cross-functional collaboration: Partner with revenue cycle, compliance, and clinical leadership to align utilisation performance with quality and financial goals.
AI training support: Annotate AI outputs and provide structured clinical feedback for healthcare AI training datasets.

Qualifications

Minimum 5+ years of experience in utilisation management, case management, clinical review, or related healthcare operations.
At least 2 years in a management or leadership role.
Active clinical licensure, with RN required for nursing-focused roles and MD/DO preferred for physician advisor roles.
Deep knowledge of InterQual, MCG, Milliman, or equivalent medical-necessity criteria.
Strong expertise in CMS Two-Midnight Rule requirements, observation status regulations, inpatient criteria, and clinical review processes.
Experience managing or participating in physician advisor programs and payer peer-to-peer review processes.
Strong ability to interpret medical records and critically assess clinical documentation.
Exceptional written and verbal English communication skills.
High attention to detail with the ability to evaluate complex clinical scenarios and AI-generated utilisation management outputs.
Must be based in the United States.