Senior Manager, Utilization Management & Claims

Akido•Chino, CA

4d•$100,000 - $140,000•Onsite

About The Position

We are seeking a Senior UM & Claims Manager to lead and oversee Utilization Management and Claims operations across multiple IPAs supported by our MSO in Southern California. Reporting to the Head of AI Operations (COO of the MSO), this role is critical to ensuring regulatory compliance, operational excellence, and strong health plan relationships. You will serve as the primary operational point of contact for contracted health plans while leading a team of 5–10 professionals across UM and Claims. You will work in partnership with the AI Operations team to implement creative automations and efficiency initiatives. This is an opportunity to build scalable, high-performing workflows and drive measurable improvements in compliance, timeliness, and financial performance.

Requirements

Minimum 10 years of experience in Utilization Management, Claims, Managed Care, or IPA/MSO operations
Deep expertise in regulatory requirements governing UM and delegated claims functions in California (preferred)
Experience overseeing health plan audits, delegated oversight reporting, ODAG logs, and claims timeliness reporting (preferred)
Demonstrated experience managing teams in a multi-IPA or delegated risk environment (preferred)
Strong knowledge of authorization workflows, medical necessity criteria, and claims adjudication processes (preferred)
Experience serving as a primary operational contact for health plans (preferred)
Proficiency in platforms such as EZCap, EZNet, EMR systems, reporting tools (e.g., Crystal Reports), and health plan portals (preferred)
Exceptional organizational, analytical, and process improvement skills
Strong leadership presence with the ability to drive accountability and cross-functional collaboration
Comfortable working onsite in Chino, CA

Responsibilities

Provide strategic oversight of all UM and delegated Claims operations across multiple IPAs, ensuring regulatory compliance and operational efficiency
Lead, mentor, and manage a team of 5–10 UM and Claims professionals, setting performance standards and ensuring accountability
Serve as the primary operational liaison for contracted health plans, responding to inquiries, performance concerns, reporting requirements, and escalations
Oversee all health plan audits (UM and Claims), coordinating preparation efforts and ensuring readiness, accuracy, and timely submission of materials
Ensure adherence to regulatory timelines for authorizations, claims adjudication, payment processing, and reporting (ODAG logs, timeliness reports, UMC/UMCIS reports)
Monitor and improve key performance metrics including denial rates, claims timeliness, audit outcomes, and documentation accuracy
Oversee authorization workflows, queue management, escalation processes, and medical necessity review frameworks
Direct delegated claims operations including intake, adjudication oversight, check runs, reporting, and corrective action implementation
Maintain and update UM and Claims policies and procedures in alignment with regulatory and health plan requirements
Partner with executive leadership to identify process improvements, system enhancements, and automation opportunities to scale MSO operations
Create and maintain SOP's for all core workflows