Utilisation Management / Case Management leader (RN/Physician-advisor) | $100-$150/hr Remote
Overview
Elion Health is looking for seasoned Utilisation Management and Case Management leaders — including RN UM directors, case management managers, and physician advisors — to help evaluate and refine AI tools that assist with clinical review, medical-necessity decisions, and care coordination. In this contract role, you'll bring your real-world expertise directly into the development of next-generation AI systems, shaping how they support value-based care and improve utilisation performance.
What You'll Do9
- 1Direct daily UM/CM operations including concurrent and retrospective reviews, discharge planning, and care coordination across the care continuum.
- 2Assess AI-generated medical-necessity determinations and clinical review outputs for accuracy and clinical soundness, providing structured feedback to improve the AI's performance.
- 3Conduct clinical reviews against established criteria such as InterQual, MCG, or Milliman to support admission, continued stay, and level-of-care decisions.
- 4Manage the physician advisor program to handle complex UM cases, peer-to-peer reviews with payers, and denial appeal processes.
- 5Collaborate with multidisciplinary teams — including clinical staff, payers, and post-acute providers — to ensure smooth care transitions and effective discharge planning.
- 6Track and report on key UM/CM metrics like avoidable days, denial rates, observation-to-inpatient conversion ratios, and readmission numbers.
- 7Ensure compliance with CMS Conditions of Participation, the Two-Midnight Rule, and other payer-specific UM requirements.
- 8Work closely with revenue cycle, compliance, and clinical leadership to align UM activities with financial and quality goals.
- 9Annotate AI outputs and deliver structured clinical feedback to help train and refine AI datasets.
Requirements6
- 1At least 5 years of experience in utilisation management, case management, or clinical review, with a minimum of 2 years in a leadership capacity.
- 2Active clinical licensure — RN required; MD/DO preferred for physician-advisor roles — along with deep expertise in medical-necessity review.
- 3Strong command of InterQual, MCG, or Milliman clinical review criteria and familiarity with CMS regulations around observation status and inpatient criteria.
- 4Proven ability to manage physician advisor programs and handle payer peer-to-peer reviews and denial appeals.
- 5Excellent written and verbal communication skills in English, with high attention to detail for evaluating clinical documentation and AI-generated outputs.
- 6Preferred certifications such as CPUR, ACM, or CCM; experience with UM software platforms like Allscripts is a plus.
Who Should Apply
This role is ideal for experienced UM and CM leaders who want to apply their clinical and operational knowledge to cutting-edge healthcare AI. You should be comfortable evaluating AI-driven recommendations and providing detailed clinical feedback, have a strong track record of managing review processes and teams, and be excited about shaping the future of value-based care through technology.
Salary Insight
Compensation is $100-$150 per hour, based on experience and credentials.
Application Tip
When applying, emphasize your hands-on experience with specific UM criteria like InterQual or MCG and include examples of how you've improved key metrics (e.g., denial rates or avoidable days) — this directly shows your value in helping train AI systems.
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