Utilization Management
Streamline reviews to ensure effective, appropriate care delivery.
The Challenge
Inefficiencies stall care and inflate administrative costs
Fragmented intake
Manual faxes and unstructured data create massive bottlenecks and errors.
Documentation overload
Reviewers waste hours scanning irrelevant records for clinical evidence.
Regulatory pressure
Strict CMS mandates demand faster determinations and total transparency.
Provider abrasion
Slow, opaque authorization processes damage essential payer-provider relationships.
Our Solution
From manual reviews to automated, evidence-based authorizations.
Leverage AI-driven policy management to automate approvals, ensure compliance, and optimize decision-making with precision.
Interoperability that goes beyond CRD, DTR, and PAS requirements. Enable a touchless prior authorization experience that reduces provider abrasion and optimizes member outcomes.
Automate workflow rules to streamline processes, reduce manual effort, and improve operational efficiency in real time.
Empower smarter, automated determinations that drive consistency, policy accuracy, and administrative efficiency in utilization management.
Optimize intelligent routing to ensure the right tasks reach the right teams, accelerating reviews and enhancing collaboration.
Jumpstart your request intake processes with ready-to-use, customizable templates
Efficiently manage appeals and grievances with streamlined workflows that ensure compliance and timely resolutions.
Empower providers with a user-friendly portal to submit, track, and manage authorization requests seamlessly.
AI-powered fax automation extracts, structures, and auto-generates UM requests, reducing manual work and speeding up processing.
Seamless peer-to-peer MD review scheduling—letting providers self-schedule Outlook-integrated appointments to accelerate UM decisions.
Agentic AI
Our AI agents accelerate utilization management.
Prior Authorization Review Agent
Suggests evidence-based plans of care tailored to patient needs.
Document Review Agent
Analyze customer service call transcripts to identify care management opportunities.
Care Plan Recommendation Agent
Suggests evidence-based plans of care tailored to patient needs.
Gap Closure Agent
Improve quality scores and incentive performance through proactive, data-driven gap identification.
Risk Adjustment Coding Agent
Improve quality scores and incentive performance through proactive, data-driven gap identification.
Data Platform
Our Unified Data Platform is the foundation of our solutions
Unified
data
Harmonize fragmented data into a platform built for healthcare to ensure seamless integration and effortless data management.
Actionable
intelligence
Trigger both human and automated interventions at the right moments to improve quality, reduce administrative burden, and lower medical costs for over 43 million lives.
Event-driven
workflow
Deliver personalized, context-rich workflows by transforming data into real-time insights and eliminating unnecessary administrative tasks through automation.
Case Studies
See how we’ve helped others with utilization management.
HarmonyCare Health Plan
“From day one, Medecision treated us like partners, not just clients. Their implementation team made onboarding smooth and surprisingly fast, and their support team continues to feel like an extension of our own staff.”
Hawaii Medical Service Association
“I’ve enjoyed working with the Medecision team since 2003. They’re very professional, knowledgeable and energetic. They inspire me to go the extra mile, to work harder. We started years ago with utilization management workflow, administration and reporting. By listening to customer feedback, Medecision has a positive impact on healthcare. Its solutions and services continue to help us achieve our vision of building a healthier, happier Hawaii.”
Health Home Partners of Western NY
“We were able to leverage the technology to help us find our patients, evaluate acuity, prioritize and coordinate actions, even when all other services were down.”
Brand New Day
“We’re always looking for ways to make our technology do more, and Medecision is a big help. We were able to configure our system to process authorizations much more easily for all of our Medicare Advantage members. Our physicians flock to Medecision once they learn their members’ risk scores – including pharmacy and lab data – are there and that they can automate their own authorizations. We all like the idea of having everything coordinated in one system. That’s Medecision.”