Utilization management (UM)

Utilization management encompasses a range of clinical and operational activities that help health plans review requested services before, during, or after care is delivered.

Common utilization management workflows may include:

• prior authorization review
• medical necessity determination
• concurrent review
• retrospective review
• clinical policy application
• evidence and documentation review

Traditionally, utilization management has often been viewed primarily as an authorization function focused on transaction processing. Today, many health plans are evolving utilization management into a more strategic capability that influences care access, provider experience, operational performance, and regulatory readiness.

Modern utilization management increasingly emphasizes connected clinical intelligence, transparent workflows, and evidence-based decision support that balance speed, consistency, and appropriate clinical oversight.

Why It Matters

Utilization management affects care access, provider experience, operational efficiency, and medical expense management.

Fragmented workflows, manual processes, and inconsistent clinical documentation can create administrative burden, slow care decisions, and reduce visibility across the review process. For providers, these inefficiencies often contribute to friction and delays that affect patient care.

As health plans face growing pressure to improve care access, reduce administrative burden, and meet evolving regulatory expectations, utilization management must balance efficiency with clinical rigor, transparency, and defensible clinical and operational workflows.

Cohere Health Perspective

Many health plans are moving beyond transactional prior authorization toward more connected, clinically informed utilization management workflows.

By combining clinical intelligence, policy intelligence, workflow automation, and human expertise, plans can support faster, more transparent reviews while maintaining appropriate clinical oversight. The goal is not to automate clinical judgment, but to surface relevant information that supports informed, consistent, and defensible decisions across utilization management operations.