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White Paper

Smart Utilization: Five Pillars for the Future of Utilization Management

Artificial Intelligence (AI) is a new and exciting entrant within the discipline of utilization management; while AI has been used elsewhere within the care continuum, the “aha” moment has finally reached case management and utilization review.

“We’re seeing a surge in interest for artificial intelligence and machine learning solutions in case management and utilization review – and it’s about time,” says Michelle Wyatt, Director of Clinical Best Practices at XSOLIS.

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“[When] we have the same data, the thing we should be [discussing] is medical necessity, not the rules, not the platform, not workflow, not missed phone calls, not missed authorizations, not missed deadlines, that’s what you want from your payers and that’s the kind of relationship that benefits everyone."

Sherri Ernst

Revenue Integrity and UM Officer, Covenant Health

5 Key Pillars

  • Technology-Supported Case Review 
  • Intelligent Medical Necessity Determinations
  • Utilization Management by Exception 
  • Payer Collaboration 
  • Human-Centered Care Continuum