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AI-powered utilization
management

Streamline prior authorizations, reduce provider friction, and 
control medical costs with intelligent, data-driven solutions.

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The new era of utilization management

Traditional utilization management (UM) is often slow, manual, and a source of frustration for both providers and members. It’s time for a smarter approach. EXL combines generative AI, predictive analytics, and deep clinical expertise to transform UM into a strategic lever for cost control and quality improvement. We help payers automate intake, accelerate approvals, and focus clinical resources where they matter most.

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Common challenges:

High administrative costs from manual case reviews and data entry.

Provider abrasion caused by lengthy turnaround times and complex submission processes.

Inconsistent application of clinical criteria across review teams.

Missed opportunities to guide members toward high-value care.

Proven results

Our intelligent UM solutions deliver measurable value.

96%
reduction in pre-certification case handling time.
30%
decrease in administrative costs through AI-driven automation.
15%
improvement in auto-approval rates for routine requests.

The EXL advantage

Why do leading health plans choose EXL for UM transformation?

AI-first automation

<p>We use AI and machine learning to read clinical documentation, extract relevant data, and automate up to 70% of the intake and authorization process. This dramatically reduces manual effort and accelerates decision-making.</p>

Clinical and data expertise

<p>Our teams are a unique blend of registered nurses, data scientists, and clinical specialists. This allows us to build clinically sound AI models that ensure appropriate care while streamlining workflows.</p>

Flexible service models

<p>You don’t have to settle for a one-size-fits-all solution. We offer end-to-end delegated services, staff augmentation to handle volume spikes, or standalone technology solutions to enhance your existing teams.</p>

Gold carding and provider analytics

<p>Our analytics identify high-performing providers who are candidates for "gold carding," allowing you to strategically remove prior authorization requirements and reduce provider abrasion without increasing risk.</p>

Powering smarter utilization management

Our integrated platform delivers efficient, compliant, and automated workflows for both utilization and case management. The platform brings together medical, behavioral, and social determinants data to create a holistic view of each member, enabling smarter clinical decisions and proactive interventions.

Analytics-enabled workflows streamline authorizations and case reviews.

Analytics-enabled workflows streamline authorizations and case reviews.

Flexible, configurable operations adapt to your needs and regulatory requirements.

Flexible, configurable operations adapt to your needs and regulatory requirements.

Seamless data integration supports whole-person care and better outcomes.

Seamless data integration supports whole-person care and better outcomes.

Robust reporting tools drive transparency and continuous program improvement.

Robust reporting tools drive transparency and continuous program improvement.

Frequently asked questions

How does EXL ensure compliance with regulations like the CMS Interoperability rule?
<p>Our solutions are built for compliance. We help payers meet new requirements for electronic prior authorization (ePA) and decision timeframes by automating data exchange and accelerating case reviews.</p>
Can automation handle complex clinical reviews?
<p>Our approach is "human-in-the-loop." AI handles high-volume, low-complexity requests, while flagging complex cases that require the expertise of your clinical professionals. This frees up your best resources for the most challenging reviews.</p>
What is the implementation process like?
<p>EXL’s solutions are designed for rapid deployment. We work closely with your teams to configure workflows and integrate with your systems, ensuring a smooth transition and a quick return on investment.</p>
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Modernize your UM program

Discover how EXL’s data-driven approach can lower costs, 
improve provider relations, and ensure members get 
the right care, right away.

Schedule a demo
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