Utilization Management Nurse (Freelancer)

About Us

Deccan AI Experts is a pioneering AI company founded by IIT Bombay and IIM Ahmedabad alumni, with a strong founding team from IITs, NITs, and BITS. We specialize in high-quality human-curated data, AI-first operations, and advanced AI evaluation systems. Our global network of healthcare professionals helps train and evaluate next-generation AI models through expert clinical judgment and evidence-based medical knowledge.

About the Role

We are seeking a Utilization Management Nurse (Freelancer) to support advanced AI evaluation initiatives focused on utilization review, medical necessity determination, healthcare documentation, case management, payer guidelines, and AI-generated healthcare content evaluation.

In this role, you will evaluate AI-generated utilization review decisions, medical necessity assessments, prior authorization recommendations, clinical documentation, case summaries, and payer-related workflows. Your expertise will help improve AI systems designed for healthcare operations, clinical decision support, utilization management, and healthcare AI applications.

This position is ideal for Registered Nurses with experience in utilization management, utilization review (UR), case management, prior authorization, managed care, health insurance, or hospital care coordination.

Responsibilities

• Review AI-generated utilization review reports, prior authorization determinations, case summaries, appeal documentation, discharge plans, and clinical recommendations.
• Evaluate medical necessity using established utilization management criteria such as InterQualregistered, MCG (Milliman Care Guidelines), payer policies, and evidence-based clinical guidelines.
• Verify AI-generated recommendations for admission status, continued stay reviews, level of care determinations, discharge planning, and resource utilization.
• Identify documentation deficiencies, unsupported medical necessity decisions, coding inconsistencies, compliance issues, and patient safety concerns.
• Provide structured feedback to improve AI performance in utilization management, healthcare operations, clinical documentation, and payer workflows.
• Review peer-developed deliverables to maintain quality and consistency standards.

Requirements

• Bachelors degree (BSN) or Associate Degree in Nursing (ADN) from an accredited nursing program.
• Active Registered Nurse (RN) license in the applicable country or state of practice.
• 3+ years of hands-on experience in utilization management, utilization review, case management, managed care, health insurance, hospital care coordination, or clinical nursing.
• Performing utilization reviews and medical necessity assessments.
• Applying InterQualregistered, MCG, CMS, and payer-specific guidelines to determine appropriate levels of care.
• Reviewing inpatient, outpatient, rehabilitation, skilled nursing, and observation cases.
• Coordinating with physicians, case managers, and healthcare teams regarding authorization and discharge planning.
• Reviewing AI-generated utilization management documentation for clinical accuracy and regulatory compliance.
• Familiarity with Electronic Health Record (EHR) systems such as Epic, Cerner, Meditech, or similar platforms.
• Knowledge of ICD-10-CM, CPT, HCPCS, and DRG concepts is preferred.
• Excellent clinical reasoning, analytical thinking, and written English communication skills.
• Strong attention to detail and commitment to quality and regulatory compliance.
• Ability to work independently in a remote, fast-paced environment.

Preferred Qualifications

• Experience working for hospitals, health systems, insurance companies, managed care organizations, third-party administrators (TPAs), utilization management organizations, or government healthcare programs.
• Experience performing concurrent review, retrospective review, prospective review, appeals, denial management, or discharge planning.
• Familiarity with Medicare, Medicaid, commercial insurance, value-based care, accountable care organizations (ACOs), and population health initiatives.
• Experience evaluating AI-generated utilization review documentation, clinical decision-support systems, healthcare operations workflows, or payer-related content.
• Familiarity with Generative AI, prompt engineering, RLHF (Reinforcement Learning from Human Feedback), AI benchmarking, or healthcare AI evaluation is an advantage.
• Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Professional in Healthcare Quality (CPHQ), or utilization management certifications are highly desirable.

Why Join Us

• Competitive hourly pay: ₹1,800/hour
• Fully remote with flexible working hours.
• Opportunity to contribute to cutting-edge AI initiatives in healthcare operations, utilization management, and Generative AI.
• Exposure to advanced AI systems focused on medical necessity review, care coordination, healthcare documentation, and payer workflows.
• Flexible project-based opportunities with global teams.
• Work on next-generation AI solutions supporting hospitals, health plans, healthcare technology companies, and AI-powered clinical systems.