Utilization Management Specialist

SmarterDx

3h • Remote

About The Position

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

Requirements

• 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
• 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

Responsibilities

• 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

Benefits

• Medical, Dental & Vision – Comprehensive plans with leading insurance providers, covering 75% of your premiums, depending on the plan.
• Paid Parental Leave – Generous paid leave to support families through birth or adoption: Up to 12 weeks for parents.
• Remote-First Team – Work from anywhere in the U.S.
• Unlimited PTO & 10 Holidays – So you can relax and recharge.
• 401(k) with Traditional & Roth Options – Tax-advantaged retirement savings through Fidelity with a 4% match.
• Minimal Bureaucracy – A fast-moving, high-impact environment where you can focus on what matters.
• Incredible Teammates! – Work alongside smart, supportive, and mission-driven colleagues.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree
• Number of Employees: 51-100 employees