Rethinking Utilization Management

Better Decisions. Earlier in the Workflow.

For much of my career, utilization management has been viewed primarily through the lens of prior authorization. Success was often measured by how efficiently requests moved through the review process, how consistently medical policies were applied, and how quickly clinical determinations could be made. Those responsibilities remain essential, but over the past several years I've found myself thinking differently about the purpose of utilization management itself.

The most meaningful transformation I see isn't simply about reviewing requests more quickly or automating existing processes. It's about helping providers, clinicians, and health plans make better decisions before a prior authorization is ever submitted.

Traditionally, utilization management has operated near the end of a clinical workflow. A provider evaluates a patient, documents the clinical need, submits a request, and waits while additional information is gathered and medical necessity is reviewed. Every person involved is trying to do the right thing, yet much of the work occurs only after decisions have already been made and documentation has already been created. By that point, uncertainty, delays, and administrative burden have already become part of the experience for everyone involved.

Increasingly, I believe our products have an opportunity to shift that work much earlier.

Rather than asking providers to submit incomplete requests and respond to repeated requests for additional documentation, technology can help identify missing clinical information while care decisions are still being made. Coverage requirements can become clearer before a request is submitted. Documentation can become more complete before it reaches a nurse reviewer. Clinical evidence can be organized earlier, allowing everyone involved to spend less time chasing information and more time applying their expertise.

That subtle shift fundamentally changes the purpose of the technology.

Instead of functioning primarily as a review system, utilization management products begin serving as decision support systems. They become tools that help providers submit more complete requests, help health plans review those requests more efficiently, and ultimately reduce unnecessary delays for members waiting to receive care.

To me, that represents a much healthier direction for utilization management.

Artificial intelligence has an important role to play in that evolution, but perhaps not in the way many people expect. I don't believe the greatest opportunity lies in allowing AI to determine medical necessity. Healthcare decisions still require clinical judgment, context, and accountability. The more valuable opportunity is allowing AI to organize information, summarize lengthy medical records, identify missing documentation, and surface relevant medical policy before a human reviewer ever begins their evaluation. In that role, AI doesn't replace clinical expertise—it gives clinicians more time to apply it where it matters most.

Recent interoperability initiatives, including CMS-0057-F and the continued adoption of HL7 Da Vinci implementation guides, reinforce this broader shift across healthcare. Their long-term significance extends beyond faster turnaround times or standardized APIs. They reflect an industry increasingly focused on reducing administrative burden by allowing information to move more naturally between providers and health plans, rather than asking people to repeatedly recreate the same information in different systems.

That distinction matters because administrative burden is rarely experienced as an abstract operational problem.

It is experienced as another phone call.

Another missing document.

Another delay.

Another day spent waiting.

Throughout my career working on products supporting utilization management, care management, and clinical operations, one lesson has remained remarkably consistent. The most valuable healthcare technology isn't the technology with the longest feature list or the most sophisticated workflow. It's the technology that quietly removes unnecessary effort, allowing clinicians, providers, and operational teams to focus more of their attention on the people they serve.

As healthcare continues to evolve, I believe the future of utilization management will be measured less by how many prior authorizations we process and more by how effectively we help providers, health plans, and members make better decisions with less unnecessary complexity. When technology succeeds in reducing administrative burden before it ever reaches the review process, utilization management becomes more than a gatekeeper. It becomes a partner in delivering more timely, coordinated, and compassionate care.

The future of utilization management isn't building better review systems. It's building better decision support systems.