Utilization Manager / Reviewer - Nurse (Health Insurance) required for AI Project (USA)
We are seeking experienced utilization reviewers and managers with a nursing background that have a strong health insurance or payor‑side experience to help develop and evaluate cutting‑edge AI models for healthcare documentation and decision support. You will review de‑identified medical charts (PDF/eFax format) and assess clinical appropriateness using MCG and InterQual guidelines. Work is fully remote, asynchronous, and offers flexible weekly hours. Key Responsibilities • Chart Review & Guideline Assessment: Review de‑identified medical charts to determine medical necessity and level‑of‑care appropriateness based on MCG and InterQual guidelines. • Health Insurance Case Context: Apply your health plan knowledge to evaluate admissions, continued stays, and procedure requests, mirroring real‑world insurance review workflows. • Structured Case Annotation: Review and highlight key clinical details, diagnoses, interventions, and outcomes to support AI model training. • AI Model Evaluation: Compare AI‑generated utilization review outputs against established guidelines and clinical judgment, providing structured feedback to improve model accuracy and fairness. • Flexible Review Times: Cases can range from 5 minutes to 4 hours, depending on complexity and document volume. Qualifications • Professional Background: Licensed RN, Utilization Review Specialist with experience in health insurance and payor‑side utilization management • Guideline Knowledge: Proficient in MCG and InterQual medical necessity criteria. Experience applying these in health plan or UM settings is essential. • Language: Professional English fluency for written deliverables. • Technical Skills: Comfortable working digitally with PDF/eFax records and structured annotation tools (training provided). Legal Status • Right to work in your country of residence. • Engagement is as an independent contractor. Why Join Us? • Flexible Work: Remote and asynchronous work. • Competitive Compensation: Hourly rates paid on a weekly basis. • Professional Insight: Collaborate on next‑generation AI models shaping the future of healthcare. • Skill Development: Gain domain training in data labeling, AI quality evaluation, and model interpretability. Apply tot his job