Utilization Management Lead — Inpatient Case Management (RN)

 

 

 

The Opportunity

 

The Utilization Management Lead, Inpatient Case Management, is responsible for leading Akido's inpatient case management function across three pillars: inpatient status determination, transitions of care, and complex case management. This is a hands-on role. The Lead reviews and determines status for delegated inpatient and SNF admissions, owns post-discharge transitions for members leaving those facilities, and carries the complex case management caseload for high-risk members, including direct member and caregiver outreach. As the program moves past its current MVP, the Lead will refine stratification, outreach, and documentation standards, operationalize admission and discharge notification workflows, and build the team structure needed to scale as membership grows. The role sits 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.

What you'll do

Pillar 1: Inpatient status determination

• Perform initial admission and concurrent review 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 and maintain compliance with notification and turnaround requirements

Pillar 2: Transitions of care

• Own post-discharge follow-up for members discharged from inpatient and skilled nursing facilities: respond to admission and discharge notifications, complete outreach and medication reconciliation, and coordinate follow-up visits within required timeframes
• Operationalize the ADT/TCM notification feed: define which events trigger outreach, set response timeframes and escalation paths, and validate notifications against facility admissions
• Coordinate discharge planning with hospital and SNF case managers, home health, DME, and PCP offices to prevent avoidable readmissions

Pillar 3: Complex case management and member outreach

• Carry the complex case management caseload for high-risk members: identify and enroll eligible members, 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, documenting time and activities
• Define and apply case closure criteria and transition members to lower-intensity care management when appropriate

Program scale and compliance

• Scale the program past MVP: refine risk stratification and enrollment criteria, outreach cadence, care plan standards, documentation requirements, and closure criteria
• Finalize and maintain the policies and procedures required for delegated inpatient review and complex case management, and keep case files audit-ready
• Prepare for and support health plan audits, and produce the 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

Leadership and team building

• Report program performance to the UM Manager and Medical Director, and recommend workflow changes based on the data
• Build the team structure as the program scales: define roles, caseload distribution, and coverage model; coach, train, and onboard case management staff added 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 for PCPs across Akido clinics and the contracted network

Who you are

• Active, unrestricted California RN license (required)
• 5+ years of clinical experience, including 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
• Experience building or scaling a care management program, or demonstrated ownership of program-level outcomes (preferred)
• Certified Case Manager (CCM) or equivalent certification (preferred)
• Experience in a delegated MSO or health plan environment, including preparation for delegation audits (preferred)
• Working knowledge of CMS and DMHC requirements for delegated UM and case management, HEDIS Transitions of Care measures, and readmission drivers
• Experience with EZCap or comparable managed care systems (preferred)
• Strong clinical assessment and care planning skills, with attention to documentation quality
• Comfortable with data: able to read program reports, spot 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
• Bilingual English/Spanish (preferred)