Enhancing Utilization Management for Healthcare MCOs through AI-Driven Automation

Enhanced our customer’s Utilization Management SaaS platform that empowers healthcare Managed Care Organizations(MCOs) to optimize clinical review processes, reduce costs, and improve member experience. Architected on Microsoft Azure with a secure .NET backend, PostgreSQL database, and React front end. Leveraged Claude Sonnet 3.7, integrated via Azure Databricks, drives advanced NLP for automating prior authorization, clinical reviews, and case prioritization—ensuring consistent, evidence-based decision-making. The system intelligently prioritizes cases, flags potential overutilization, and recommends appropriate care pathways. Seamless integration with claims module, EHR, and HIEs enhancing decision speed. Actionable dashboards and intelligent automation reduced manual workload and turnaround times by 40%, empowering payers to focus on complex cases, ensure compliance, and drive operational efficiency while maintaining transparency and fairness in utilization decisions.