GLOSSARY - HEALTHCARE
What is Utilization Management?
Last reviewed:
Quick Answer
Utilization Management (UM) is the evaluation of medical necessity, appropriateness, and efficiency of healthcare services. AI-powered UM automates prior authorization reviews, concurrent reviews, and retrospective reviews to ensure services are medically necessary and align with evidence-based guidelines.
Definition
**Utilization Management** balances quality patient care with appropriate resource use. AI systems evaluate clinical documentation against medical policies, identify over/under-utilization patterns, and recommend appropriate care levels—all while supporting payer cost management and provider workflows.
Key Points
- Evaluates medical necessity for requested services
- Ensures care aligns with evidence-based guidelines
- Identifies utilization patterns requiring intervention
- Supports prior authorization and concurrent review
- Reduces administrative burden on clinical staff
- Maintains compliance with regulatory requirements