Utilization Management Specialist

Utilization Management Specialist

Role

The Utilization Management (UM) Specialist will play a critical role in SmarterDx’s expansion into the Utilization Management space. This role will work closely with Product and Data Science teams to apply real-world physician judgment to the development of clinical logic, workflows, and evidence interpretation that support accurate, defensible level-of-care decisions.

**This role is fully remote within the US**

What You’ll Do

• Review and refine AI-generated clinical summaries and indicators related to medical necessity, level of care, and patient status, ensuring outputs reflect real-world physician reasoning and defensibility
• Collaborate with Product and Data Science teams to define and validate clinical logic that surfaces relevant evidence and highlights potential status misalignment
• Translate clinical knowledge into prompts and guidelines for large language models
• Apply a physician advisor perspective to help model clinical gray areas where documentation quality, acuity, and trajectory matter most
• Support the design of UM workflows that assist nurses and physician advisors in efficiently reviewing cases without directing clinical decisions
• Translate utilization review standards, regulatory guidance, and clinical judgment into clear product requirements and clinical guidelines for level of care determinations
• Serve as a clinical subject matter expert for level of care determinations, escalation pathways, and payer-facing documentation expectations

What You Bring

• Physician background with experience in utilization management, physician advisory work, or medical necessity review in an acute care setting
• Strong understanding of how level-of-care decisions are evaluated, escalated, and defended over the course of a hospital stay
• Deep knowledge of CMS 2-Midnight Rule, Condition Code 44, OC72, 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.
• Comfort operating in clinical gray areas where criteria are not definitive and documentation quality materially impacts outcomes

Must Haves

• MD or DO
• Direct experience performing physician advisory work, or medical necessity determinations
• Direct experience participating in peer-to-peer reviews with payers
• Direct experience overseeing care for hospitalized patients
• Ability to clearly articulate clinical reasoning and translate it into structured logic
• Comfort working in a non-clinical, product-focused role

Nice To Haves

• Prior experience with AI prompt engineering
• Previous advising or consulting experience with healthcare technology companies
• Experience working with or overseeing physician advisor teams or UM teams
• Familiarity with denial management related to medical necessity or level of care

Compensation

• $230k-$260k base + benefits

#LI-Remote