Inpatient UM Lead: Transitions of Care & Complex Cases

Akido Labs, Inc.; Chino Hills (CA); On-site; USD 103,000 - 130,000; Full time

Job summary

Akido Labs, Inc. is seeking an Utilization Management Lead, Inpatient Case Management, to lead inpatient case management across three pillars within a California managed care environment.

The role works with the Medical Director, PCPs, facilities, health plan partners, and reports to the UM Manager. You will review admissions using criteria, coordinate transitions of care, and manage a complex caseload while scaling the program as membership grows.

Qualifications

• 5+ years of clinical experience, including inpatient utilization management and complex case management in managed care settings.
• 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 ownership of program-level outcomes (preferred).
• Certified Case Manager (CCM) or equivalent certification (preferred).
• Experience in delegated MSO/health plan environments and preparation for delegation audits (preferred).
• Working knowledge of CMS/DMHC requirements for delegated UM and case management, HEDIS Transitions of Care measures, and readmission drivers.

Responsibilities

• Perform initial admission and concurrent review for delegated inpatient and SNF admissions using criteria, determining status and level of care.
• Prepare clinical summaries and route cases to 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.
• Own post-discharge follow-up for members discharged from inpatient and SNF facilities; respond to notifications, complete outreach and medication reconciliation, and coordinate follow-up visits.
• Operationalize ADT/TCM notifications: define trigger events, response times, escalation paths, validate notifications against admissions.
• Coordinate discharge planning with hospital/SNF case managers, home health, DME, and PCP offices to prevent avoidable readmissions.
• Carry the complex case management caseload for high-risk members: enroll, assess, develop care plans with Medical Director and treating providers.
• Lead interdisciplinary care team coordination for medically and psychosocially complex populations and document time and activities.
• Define and apply case closure criteria and transition members to lower-intensity care management when appropriate.
• Scale the program past MVP: refine risk stratification, enrollment criteria, outreach cadence, care plan standards, and documentation requirements.

Skills

Inpatient utilization management

Case management

Transitions of care

CMS/DMHC knowledge

Leadership / team building

Communication with providers

Data-driven decision making

Tools

EZCap

Job description

Akido Labs, Inc. is seeking an Utilization Management Lead, Inpatient Case Management, to lead inpatient case management across three pillars within a California managed care environment.

The role works with the Medical Director, PCPs, facilities, health plan partners, and reports to the UM Manager. You will review admissions using criteria, coordinate transitions of care, and manage a complex caseload while scaling the program as membership grows.