Utilization Management Lead — Inpatient Case Management (RN)

Akido•Chino Hills, CA

10d

About The Position

The Utilization Management Lead, Inpatient Case Management, leads Akido’s inpatient case management function across inpatient status determination, transitions of care, and complex case management. This hands-on role reviews delegated inpatient and skilled nursing facility (SNF) admissions, manages post-discharge transitions, and carries a complex case management caseload for high-risk members, including direct outreach to members and caregivers. As the program scales beyond its current MVP, the Lead refines stratification, outreach, and documentation standards, operationalizes admission and discharge notification workflows, and builds the team structure needed to support membership growth. The role is within the Utilization Management department in a California managed care environment and reports to the UM Manager. It works closely with the Medical Director, primary care providers, facilities, health plan partners, and operational teams. The Lead conducts initial and concurrent reviews for delegated inpatient and SNF admissions using MCG and health plan criteria; coordinates with facility case managers; and documents determinations in EZCap. The position owns post-discharge follow-up, including outreach, medication reconciliation, follow-up visit coordination, and discharge planning with hospitals, SNFs, home health, DME, and PCP offices. The role also identifies and enrolls eligible high-risk members, completes assessments and individualized care plans, coordinates interdisciplinary care, and connects members with specialist, ancillary, and community resources. Program responsibilities include developing and maintaining policies and procedures, supporting health plan audits, producing required reports, maintaining compliance with CMS, DMHC, and health plan delegation standards, and coaching and onboarding case management staff as the program grows.

Requirements

Active, unrestricted California RN license.
At least 5 years of clinical experience, including at least 3 years combined in inpatient utilization management and complex case management in a managed care, IPA, MSO, or health plan setting.
Working knowledge of MCG criteria and inpatient status determination.
Experience with transitions of care, discharge planning, and post-acute coordination for Medicare Advantage or similar populations.
Working knowledge of CMS and DMHC requirements for delegated UM and case management, HEDIS Transitions of Care measures, and readmission drivers.
Strong clinical assessment and care planning skills, with attention to documentation quality.
Ability to read program reports, identify trends, and use them to adjust workflows.
Effective written and verbal communication with members, providers, health plan partners, and leadership.
Ability to manage competing priorities and fixed regulatory timeframes in a fast-paced environment.

Nice To Haves

Experience building or scaling a care management program, or demonstrated ownership of program-level outcomes.
Certified Case Manager (CCM) or equivalent certification.
Experience in a delegated MSO or health plan environment, including preparation for delegation audits.
Experience with EZCap or comparable managed care systems.
Bilingual English/Spanish.

Responsibilities

Perform initial admission and concurrent reviews for delegated inpatient and SNF admissions using MCG and health plan criteria, and determine appropriate status and level of care.
Prepare clinical summaries and route cases that do not meet criteria to the Medical Director within required timeframes.
Coordinate with facility case managers regarding continued stay, discharge readiness, and post-acute placement.
Document reviews, determinations, and rationale in EZCap, meeting notification and turnaround requirements.
Own post-discharge follow-up for members discharged from inpatient and skilled nursing facilities, including responding to notifications, completing outreach and medication reconciliation, and coordinating follow-up visits.
Operationalize the ADT/TCM notification feed by defining outreach-triggering events, response timeframes, and escalation paths, and validating notifications against facility admissions.
Coordinate discharge planning with hospital and SNF case managers, home health, DME, and PCP offices to help prevent avoidable readmissions.
Identify and enroll eligible high-risk members, complete comprehensive assessments, and develop individualized, patient-centered care plans with the Medical Director and treating providers.
Lead interdisciplinary care team coordination for medically and psychosocially complex populations, ensuring evidence-based care plans are delivered and updated.
Conduct ongoing member and caregiver outreach, medication review and reconciliation, and coordination of specialist, ancillary, and community resources; document time and activities.
Define and apply case closure criteria and transition members to lower-intensity care management when appropriate.
Refine risk stratification and enrollment criteria, outreach cadence, care plan standards, documentation requirements, and closure criteria as the program scales.
Finalize and maintain policies and procedures for delegated inpatient review and complex case management, and keep case files audit-ready.
Prepare for and support health plan audits, and produce monthly and quarterly transitions of care and case management reports owed to health plans.
Maintain compliance with CMS, DMHC, and health plan delegation standards, including timeliness, notification, and documentation requirements.
Report program performance to the UM Manager and Medical Director and recommend workflow changes based on data.
Build the team structure as the program scales, including defining roles, caseload distribution, and coverage; coach, train, and onboard case management staff.
Partner with UM nurses and coordinators, Claims, Eligibility, Network, and Operations to resolve member and provider issues.
Serve as the clinical point of contact for health plan care management partners and PCPs across Akido clinics and the contracted network.