Utilisation Management Leader for AI Evaluation (RN/Physician Advisor)

Drive clinical review and care-coordination excellence by applying utilisation management and case management leadership to evaluate and refine AI tools that support medical necessity determinations, clinical review workflows, and discharge planning. In this role you will combine hands-on UM/CM operations experience with clinical judgment to validate AI outputs, annotate examples for model training, and help shape systems that reduce unnecessary care and advance value based care objectives.

• Lead utilisation management and case management operations, including concurrent review, retrospective review, discharge planning, and care coordination.
• Evaluate AI generated medical necessity determinations, clinical review outputs, and decision support recommendations for accuracy and clinical appropriateness.
• Perform and oversee clinical reviews using InterQual, MCG, or Milliman guidelines to support admission, continued stay, and level of care decisions.
• Manage physician advisor activities to support complex UM cases, peer to peer review requests, and denial appeals.
• Coordinate with clinical teams, payers, and post acute providers to enable appropriate care transitions and discharge plans.
• Monitor UM and CM performance metrics, including avoidable days, denial rates, observation versus inpatient conversion rates, and readmission rates.
• Ensure compliance with CMS Conditions of Participation, the Two Midnight Rule, and payer specific utilisation management requirements.
• Collaborate with revenue cycle, compliance, and clinical leadership to align UM performance with financial and quality goals.
• Annotate AI outputs and supply structured clinical feedback to build and improve AI training datasets.

• Minimum 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 roles preferably filled by MD or DO.
• Demonstrated expertise using InterQual, MCG, or Milliman clinical review criteria.
• Strong knowledge of the CMS Two Midnight Rule, observation status regulations, and inpatient criteria.
• Experience managing physician advisor programs and payer peer to peer review processes and denial appeal workflows.
• Exceptional written and verbal English communication skills.
• High attention to detail and ability to critically evaluate clinical documentation and AI generated UM outputs.

• Credentials such as CPUR, ACM, or CCM.
• MD or DO with prior experience as a physician advisor for utilisation management.
• Experience with UM software platforms, for example Allscripts or other utilisation management systems.
• Familiarity with AI tools and comfort evaluating AI generated clinical review content.
• Background working in health systems, ACOs, or value based care organisation UM programs.

• Location: Remote.
• Employment type: Hourly engagement.
• Work will focus on evaluating AI driven clinical review tools and providing structured annotations and feedback to support model development.

Hourly pay range: 100 to 150 per hour.

• Must hold an active clinical license, RN required; MD or DO preferred for physician advisor roles.
• Ability to demonstrate the required UM and leadership experience, including use of InterQual, MCG, or Milliman criteria.
• Strong English language proficiency for written and verbal clinical communication.