Utilization Management
Appropriate care. Defensible decisions.
Efficient operations.
Effective UM programs are not about denial rate management. They are about applying clinical criteria consistently, documenting decisions defensibly, and building workflows that don't create unnecessary friction for clinicians or members.
What We Deliver
UM consulting across the full program lifecycle.
Whether you're standing up a UM program from scratch, rebuilding one that's underperforming, or aligning an existing program to updated CMS or NCQA requirements, we work with your clinical and operational teams directly, not through generic frameworks.
Program Design & Implementation
UM program structure, staffing model design, role definition, and workflow mapping from prior auth through discharge planning.
InterQual & MCG Criteria Application
Criteria selection, training, and audit to ensure clinical reviewers are applying evidence-based criteria consistently and defensibly.
Prior Authorization Workflow
End-to-end PA process design, intake, clinical review, turnaround time compliance, and decision notification in line with CMS and state requirements.
Peer-to-Peer & Appeals Support
P2P and appeal workflow design, MD advisor engagement, and documentation standards that hold up under IRO review.
Compliance Alignment
Gap analysis against current CMS prior auth rules, NCQA UM standards, and state-specific requirements, with remediation roadmap.
Regulatory Context
CMS has materially expanded prior authorization requirements for Medicare Advantage plans. The Interoperability and Prior Authorization Final Rule (CMS-0057-F) mandates electronic PA infrastructure, new transparency requirements, and accelerated decision timelines.
Organizations that don't have compliant UM programs in place face both audit exposure and member experience risk. We help you build programs that are compliant now and designed to absorb future regulatory change.
Talk to our UM team →Is your UM program built to hold up under scrutiny?
We'll assess your program against current CMS and NCQA standards and identify where the gaps are.