Utilization Management & Claims Senior Manager

<div class="content-intro"><p>Akido builds AI-powered doctors<strong>.</strong> 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.</p> <p>Serving 500K+ patients across California, Rhode Island, and New York, Akido offers primary and specialty care in 26 specialties—from serving <a href="https://www.fastcompany.com/91231274/how-one-la-doctor-is-using-ai-to-help-homeless-communities-get-medical-care">unhoused communities</a> in Los Angeles to <a href="https://www.wsj.com/articles/the-ai-doctor-will-see-new-york-ride-share-drivers-now-5ba53e6c?mod=Searchresults_pos1page=1">ride-share drivers</a> in New York.</p> <p>Founded in 2015 (YC W15), Akido is expanding its risk-bearing care models and scaling ScopeAI, its breakthrough clinical AI platform. <a href="https://www.businesswire.com/news/home/20250515102298/en/Akido-Raises-%2460-Million-Series-B-to-Expand-Reach-of-ScopeAI-its-Breakthrough-Health-Artificial-Intelligence">Read more about Akido’s $60M Series B</a>. More info at <a href="http://Akidolabs.com">Akidolabs.com</a>.</p></div><p><strong>The Opportunity </strong></p> <p data-start="190" data-end="848">We are seeking a Senior UM Claims Manager to lead and oversee Utilization Management and Claims 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 and Claims. 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. </p> <p><strong>What you’ll do </strong></p> <ul> <li data-start="874" data-end="1027"> <p data-start="876" data-end="1027">Provide strategic oversight of all UM and delegated Claims operations across multiple IPAs, ensuring regulatory compliance and operational efficiency</p> </li> <li data-start="1028" data-end="1158"> <p data-start="1030" data-end="1158">Lead, mentor, and manage a team of 5–10 UM and Claims professionals, setting performance standards and ensuring accountability</p> </li> <li data-start="1159" data-end="1319"> <p data-start="1161" data-end="1319">Serve as the primary operational liaison for contracted health plans, responding to inquiries, performance concerns, reporting requirements, and escalations</p> </li> <li data-start="1320" data-end="1473"> <p data-start="1322" data-end="1473">Oversee all health plan audits (UM and Claims), coordinating preparation efforts and ensuring readiness, accuracy, and timely submission of materials</p> </li> <li data-start="1474" data-end="1644"> <p data-start="1476" data-end="1644">Ensure adherence to regulatory timelines for authorizations, claims adjudication, payment processing, and reporting (ODAG logs, timeliness reports, UMC/UMCIS reports)</p> </li> <li data-start="1645" data-end="1778"> <p data-start="1647" data-end="1778">Monitor and improve key performance metrics including denial rates, claims timeliness, audit outcomes, and documentation accuracy</p> </li> <li data-start="1779" data-end="1895"> <p data-start="1781" data-end="1895">Oversee authorization workflows, queue management, escalation processes, and medical necessity review frameworks</p> </li> <li data-start="1896" data-end="2036"> <p data-start="1898" data-end="2036">Direct delegated claims operations including intake, adjudication oversight, check runs, reporting, and corrective action implementation</p> </li> <li ... (truncated, view full listing at source)