Utilization Management Lead — Inpatient Case Management (RN)

Akido•Chino Hills, CA

14h•$103,000 - $130,000

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 is a hands-on role responsible for reviewing delegated inpatient and skilled nursing facility (SNF) admissions, managing post-discharge transitions, and carrying a complex case management caseload for high-risk members, including direct outreach to members and caregivers. As the program grows beyond its current MVP, the Lead will refine stratification, outreach, and documentation standards; operationalize admission and discharge notification workflows; and develop the team structure needed to scale. The role is within the Utilization Management department in a California managed care environment, reports to the UM Manager, and works closely with the Medical Director, PCPs, facilities, health plan partners, and operational teams.

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 findings 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 for determination within required timeframes.
Coordinate with facility case managers on continued stay, discharge readiness, and post-acute placement.
Document reviews, determinations, and rationale in EZCap, maintaining compliance with notification and turnaround requirements.
Own post-discharge follow-up for members discharged from inpatient and skilled nursing facilities, including responding to admission and discharge notifications, completing outreach and medication reconciliation, and coordinating follow-up visits within required timeframes.
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 prevent avoidable readmissions.
Identify and enroll eligible high-risk members in complex case management, complete comprehensive assessments, and develop individualized, patient-centered care plans in collaboration 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.
Scale the program beyond MVP by refining risk stratification and enrollment criteria, outreach cadence, care plan standards, documentation requirements, and closure criteria.
Finalize and maintain policies and procedures for delegated inpatient review and complex case management, keeping case files audit-ready.
Prepare for and support health plan audits, and produce monthly and quarterly transitions of care and case management reports for 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 by defining roles, caseload distribution, and coverage model; coach, train, and onboard case management staff as membership grows.
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.