Utilization Management Manager

Akido builds AI-powered doctors. Akido is the first AI-native care provider, combining cutting-edge technology with a nationwide medical network to address America’s physician shortage and make exceptional healthcare universal. Its AI empowers doctors to deliver faster, more accurate, and more compassionate care.

Serving 500K+ patients across California, Rhode Island, and New York, Akido offers primary and specialty care in 26 specialties—from serving unhoused communities in Los Angeles to ride-share drivers in New York.

Founded in 2015 (YC W15), Akido is expanding its risk-bearing care models and scaling ScopeAI, its breakthrough clinical AI platform. Read more about Akido’s $60M Series B. More info at Akidolabs.com.

The Opportunity

We are seeking a Utilization Management Manager to lead and oversee Utilization Management operations across multiple IPAs supported by our MSO in Southern California. Reporting to the Head of AI Operations (COO of the MSO), this role is critical to ensuring regulatory compliance, operational excellence, and strong health plan relationships. You will serve as the primary operational point of contact for contracted health plans while leading a team of 5–10 professionals across UM. You will work in partnership with the AI Operations team to implement creative automations and efficiency initiatives. This is an opportunity to build scalable, high-performing workflows and drive measurable improvements in compliance, timeliness, and financial performance. 

What you’ll do

• Provide strategic and operational oversight of all UM operations across multiple IPAs, ensuring regulatory compliance and operational efficiency

• Lead day-to-day operations including prior authorizations, concurrent review, and retrospective review

• Lead, mentor, and manage a team of 5–10 UM professionals, including UM Nurses and coordinators, setting performance standards and ensuring accountability

• Serve as the primary operational liaison for contracted health plans, responding to inquiries, performance concerns, reporting requirements, and escalations

• Ensure medical necessity determinations align with MCG guidelines and hierarchies as well as health plan policies

• Oversee all UM-related health plan audits, coordinating preparation efforts and ensuring readiness, accuracy, and timely submission of materials (including but not limited to pre-delegation audits, annual delegation audits, focused and adhoc audits, and owning Corrective Action Plans)

• Develop and manage Correct Action Plans for audit findings, TAT failures, and quality deficiencies 
• Oversee denial processes and ensure compliant member/provider communications 

• Ensure adherence to regulatory timelines for authorizations and reporting (ODAG logs, timeliness reports, UMC/UMCIS reports)

• Oversee authorization workflows, queue management, escalation processes, and medical necessity review frameworks

• Maintain and update UM policies and procedures in alignment with regulatory and health plan requirements

• Serve as the primary owner of UM Delegation compliance, ensuring adherence to all delegated functions by healht plan contracts and maintaining readiness for oversight by health plans according to DMHC, CMS and NCQA standards

• Partner with executive leadership to identify process improvements, system enhancements, and automation opportunities to scale MSO operations

• Create and maintain SOP's for all core workflows

Who you are 

• Active RN / LVN License (California)

• Minimum 10 years of experience in Utilization Management, Managed Care, or IPA/MSO operations

• Strong knowledge of DHMC / CMS regulations, prior authorization processes, and TAT requirements

• Deep expertise in regulatory requirements governing delegated UM functions in California

• Familiarity with MCG and Hierarchies 

• Experience overseeing health plan audits, delegated oversight reporting, and ODAG logs 

• Demonstrated experience managing teams in a multi-IPA or delegated risk environment (preferred)

• Strong knowledge of authorization workflows, and medical necessity criteria (preferred)

• MCG Certified (preferred)

• Experience serving as a primary operational contact for health plans (preferred)

• Proficiency in platforms such as EZCap, EZNet, EMR systems, reporting tools (e.g., Crystal Reports), and health plan portals (preferred)

• Exceptional organizational, analytical, and process improvement skills 

• Strong leadership presence with the ability to drive accountability and cross-functional collaboration

• Comfortable working onsite in Chino, CA

Benefits 

• Health benefits include medical, dental and vision
• Paid leaves
• 401K
• Life insurance

Akido Labs, Inc. is an equal opportunity employer, and we encourage qualified applicants of every background, ability, and life experience to contact us about appropriate employment opportunities.