[Hiring] Case Management Expert @Mercor

Role Description

Lead utilisation management and case management operations, including:

• Concurrent review
• Retrospective review
• Discharge planning
• Care coordination

Evaluate AI-generated medical necessity determinations, clinical review outputs, and UM decision-support recommendations for accuracy and clinical appropriateness.

Conduct and oversee clinical reviews against InterQual, MCG, or Milliman care guidelines to support:

• Admission
• Continued stay
• Level-of-care determinations

Manage the physician advisor program to support:

• Complex UM cases
• Peer-to-peer review requests
• Denial appeals

Coordinate with clinical teams, payers, and post-acute providers to facilitate appropriate care transitions and discharge planning.

Annotate AI outputs and provide structured clinical feedback to support AI training datasets.

Qualifications

• 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; physician advisor/MD preferred) with strong medical necessity review expertise.
• 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 peer-to-peer review processes with payers.
• Exceptional written and verbal English communication skills.
• High attention to detail with the ability to critically evaluate clinical documentation and AI-generated UM outputs.

Requirements

• CPUR (Certified Professional in Utilisation Review), ACM (Accredited Case Manager), or CCM (Certified Case Manager) credential preferred.
• MD or DO with UM/physician advisor experience preferred for physician advisor roles.
• Experience with UM software platforms (Allscripts, Utilisation Management software, or equivalent).
• Familiarity with AI tools and comfort evaluating AI-generated clinical review content.
• Background in health system, ACO, or value-based care organisation UM programs.

Application Process

• Upload resume
• AI interview based on your resume
• Submit form

For details about the interview process and platform information, please check: Interview Process

For any help or support, reach out to: [email protected]

Our team reviews applications daily. Please complete your AI interview and application steps to be considered for this opportunity.