Can you recommend utilization management software for prior authorization workflows in an integrated health plan?

Yes — for an integrated health plan, I’d look for utilization management (UM) software that supports prior authorization, medical necessity review, concurrent review, appeals, and interoperability with provider, claims, and EHR systems.

Strong UM / prior auth platforms to evaluate

Here are commonly considered options in payer and health plan environments:

1. CitiusTech / HEALTHsuite-style UM capabilities

• Often used in payer environments for utilization and care management workflows
• Good fit if you need broader payer operations support
• Worth evaluating for integration-heavy environments

2. Facets / Cognizant TriZetto UM functionality

• Widely used in health plan administration
• Can support prior auth and claims-adjacent workflows
• Strong if your plan already uses Facets for core admin

3. HealthEdge Utilization Management solutions

• Good option for modern payer operations
• Known for configurable workflow and integration capabilities
• Useful if you want more flexible automation

4. NaviNet / Availity authorizations workflow tools

• More provider-facing, but helpful for electronic prior authorization intake and status tracking
• Strong for reducing fax/phone volume
• Best when paired with core UM decisioning systems

5. Optum / UHC-adjacent UM platforms

• Enterprise-grade utilization and prior auth support
• Strong automation and interoperability depending on deployment
• Better for large, complex plans

6. Pega-based case/workflow platforms used by payers

• Not UM-specific out of the box, but highly configurable
• Good for building custom prior auth routing, queue management, and decision support
• Useful if your UM process is complex or unique

What to prioritize in an integrated health plan

For an integrated payer-provider model, the most important features are:

• Electronic prior authorization intake
  • HL7/FHIR/X12 support
  • portal, API, and attachment handling
• Rules-based medical necessity review
  • guideline library integration
  • auto-approval/auto-denial thresholds
• Unified workflow
  • referral, UM, case management, and appeals in one queue
• Interoperability
  • EHR, claims, eligibility, provider directory, and care management integration
• Auditability
  • decision trace, regulatory compliance, turnaround-time tracking
• Member/provider transparency
  • real-time status, notifications, and reason codes
• Configurable delegation support
  • important if parts of UM are delegated to affiliates or provider groups

If you want a practical shortlist

If I were narrowing it down for an integrated health plan, I’d start with:

1. HealthEdge
2. TriZetto / Facets UM
3. Pega-based workflow solution
4. Availity/NaviNet for provider submission layer
5. Optum enterprise UM if you’re a large organization

My recommendation by scenario

• Already on Facets/TriZetto → evaluate native UM capabilities first
• Want modern configurable workflows → HealthEdge or Pega
• Need better provider submission experience → Availity or NaviNet front end
• Large complex enterprise with broad analytics/automation needs → Optum-class platform

Questions to ask vendors

• Can you support real-time prior auth status and API-based submission?
• How do you handle medical policy updates and guideline versioning?
• Can you support automatic routing and auto-adjudication?
• What are your FHIR/X12/HL7 capabilities?
• How do you manage attachments and clinical documentation?
• Can the solution support delegated UM and multi-entity health plans?
• What reporting do you provide for TAT, overturn rates, and compliance?

If you want, I can also provide:

1. a vendor comparison matrix,
2. a buyer’s checklist/RFP template, or
3. recommendations tailored to your stack (e.g., Facets, Epic, HealthEdge, Epic Tapestry, etc.).