Utilization Management Specialist

Summary

Join SmarterDx as a Utilization Management Clinical Specialist and play a key role in the launch of our next product. Collaborate with Product and Data Science teams to design strategies that optimize hospital resource use and ensure appropriate patient care. Bring your clinical and operational expertise to patient status determination, documentation workflows, and utilization review, contributing to AI tools that support care coordination and medical necessity compliance. This fully remote US-based role offers the opportunity to leverage your skills to improve healthcare. SmarterDx builds clinical AI to enhance hospital chart accuracy for revenue integrity, helping them recover earned revenue and improve care quality. Become a Smartian and help optimize healthcare for everyone.

Requirements

• Strong background in utilization management or case management in an acute care setting, with hands-on experience reviewing admissions, determining levels of care, or managing discharge planning
• Deep knowledge of CMS 2-Midnight Rule, Condition Code 44, and related inpatient/outpatient guidelines
• Familiarity with tools such as InterQual® or MCG® and EMR-based workflows for utilization review and patient tracking
• Prior experience, or strong interest, in advising healthcare technology companies and building systems to support real-time utilization review
• Medical degree (RN, or similar clinical background)
• Direct experience in hospital utilization review, case management, or patient management
• Ability to grow and contribute across multiple functions as the role evolves

Responsibilities

• Review and refine AI-generated determinations of medical necessity, level of care, and patient status (e.g., inpatient vs. observation), ensuring they align with InterQual®, MCG®, and CMS guidelines
• Collaborate with cross-functional teams to define and validate rules that identify care transitions, avoidable delays, and under- or over-utilization
• Support the design of clinical workflows that assist hospital case managers and physician advisors in real-time decision-making
• Translate utilization review standards and discharge planning logic into product requirements that power automation and analytics tools
• Serve as a subject matter expert for patient status, care coordination documentation, and payer-driven utilization review processes

Preferred Qualifications

• Previous advising or consulting experience with healthcare technology companies
• Experience working with or overseeing clinical documentation improvement (CDI) or physician advisor teams
• Familiarity with denial management related to medical necessity or level of care

Benefits

• Medical, Dental & Vision – Comprehensive plans with leading insurance providers, covering 90-100% of your premiums and 70-90% for dependents, depending on the plan
• One Medical Membership – Free membership included if you enroll in a SmarterDx medical plan
• Paid Parental Leave – Up to 12 weeks of paid leave for birth or adoption
• Remote-First Team – Work from anywhere in the U.S. with a $400 home office reimbursement stipend
• Unlimited PTO & 10 Holidays – 4 of which include floating holidays so you can recognize the days that matter most to you
• Learning & Development Budget – $500 per year (prorated) for courses, books, and resources to expand your skills
• 401(k) with Traditional & Roth Options – Tax-advantaged retirement savings through Empower