Utilization Management Lead — Inpatient Case Management (RN)

The role

The Utilization Management Lead leads inpatient case management across inpatient status determination, transitions of care, and complex case management. This hands-on role involves reviewing admissions, managing post-discharge follow-up, and carrying a complex caseload for high-risk members.

What you will do

• Perform initial admission and concurrent review for delegated inpatient and SNF admissions
• Prepare clinical summaries and route cases to the Medical Director
• Coordinate with facility case managers on continued stay and discharge readiness
• Document reviews and determinations in EZCap
• Own post-discharge follow-up for members discharged from inpatient and skilled nursing facilities
• Operationalize the ADT/TCM notification feed
• Coordinate discharge planning with hospital and SNF case managers, home health, DME, and PCP offices
• Carry the complex case management caseload for high-risk members
• Lead interdisciplinary care team coordination for complex populations
• Build the team structure as the program scales

Required qualifications

• Active, unrestricted California RN license
• 5+ years of clinical experience
• 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
• Effective written and verbal communication

Nice to have

• 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

About the company

Akido builds AI-powered doctors and is an AI-native care provider. It serves 500K+ patients across California, Rhode Island, and New York.