Utilization Management: Ensuring Quality, Efficiency, and Integrity in Patient Care

Presented on December 17, 2025 by Jessica Yao MD, MBA, CHCQM-PHYADV, FAAFP This session focuses on bridging the gap between clinical decision-making and utilization management (UM) to foster alignment between providers and payers. It addresses the challenges physicians face with prior authorization, explains the payer perspective and shared goals, and reviews UM review types, common denial reasons, and the appeal process. Practical strategies to reduce delays and improve authorization workflows will be discussed, along with technology-enabled solutions that support timely, evidence-based, and patient-centered care through a collaborative UM framework. After this presentation, attendees will be able to: 1. Bridge the gap between clinical decision-making and utilization management (UM) process to promote alignment between providers and payers. 2. Understand the types of UM reviews, common denial reasons, and the appeal process. 3. Identify and apply practical strategies to reduce delays and improve authorization workflows. 4. Explore technology enabled solutions that support timely, evidence-based and patient-centered care through a collaborative UM framework.