Healthcare Operations Director | Remote

Type: Hourly contract
Compensation: $100-$150 per hour
Location: Remote
Commitment: 10-40 hrs/week

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

• Have strong relevant experience in utilisation management, case management, or clinical review, with leadership experience.
• 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.