Health plan utilization management departments have a wide range of responsibilities to maintain quality of care and manage spend. Though, when people think of utilization management, prior authorizations (PA) are at the forefront of their mind. In this research, we highlight the core functionalities of health plan utilization management departments, share their typical organization structure, highlight their vendor partnerships, and share innovative stories about what plans are doing in the utilization management space.

This research informs the entire healthcare ecosystem and is the first volume in our health plan department series.