Utilization Manager / Reviewer - Nurse (Health Insurance) required for AI Project (USA)

Licensed RN or Utilization Review Specialist with experience in health insurance and payor-side utilization management. Proficient in MCG and InterQual medical necessity criteria. Experience applying MCG and InterQual in health plan or UM settings. Professional English fluency for written deliverables. Comfortable working digitally with PDF/eFax records and structured annotation tools.

Review de-identified medical charts to determine medical necessity and level-of-care appropriateness based on MCG and InterQual guidelines. Apply health plan knowledge to evaluate admissions, continued stays, and procedure requests. Review and highlight key clinical details, diagnoses, interventions, and outcomes to support AI model training. Compare AI-generated utilization review outputs against established guidelines and clinical judgment, providing structured feedback.