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

About this role

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** - Lead utilisation management and/or case management operations, including concurrent review, retrospective review, discharge planning, and 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, and level-of-care determinations. - Manage the physician advisor program to support complex UM cases, peer-to-peer review requests, and denial appeals. - Coordinate with clinical teams, payers, and post-acute providers to facilitate appropriate care transitions and discharge planning. - Monitor UM/CM KPIs, including avoidable days, denial rates, observation vs. inpatient conversion rates, and readmission rates. - Ensure compliance with CMS Conditions of Participation, Two-Midnight Rule, and payer-specific UM requirements. - Collaborate with revenue cycle, compliance, and clinical leadership to align UM performance with financial and quality objectives. - Annotate AI outputs and provide structured clinical feedback to support AI training datasets. **Requirements** - 5+ years of experience in utilisation management, case management, or clinical review, with at least 2 years in a leadership role.