UM Transformation, Step 3: Solving Staffing Gaps When Insourcing Prior Authorization

As health plans increasingly bring prior authorization (PA) back in-house, one challenge looms large: staffing. Utilization Management (UM) is not just an administrative function — it’s a clinical cornerstone that directly impacts patient outcomes, compliance, and provider relationships. Insourcing PA without a strategic staffing plan can lead to compliance risks, delayed care, and operational inefficiencies. So, how can health plans overcome these hurdles?

The Clinical Imperative: More Than Headcount

Insourcing UM isn’t simply about filling seats. It’s about ensuring clinical depth and rigor. Prior authorization decisions require specialized expertise across multiple disciplines — nurses, pharmacists, and physicians who understand complex medical policies and can make accurate determinations. Without this depth, health plans risk:

• Regulatory compliance with turnaround time and service levels
• Inconsistent or poor quality of clinical review leading to higher appeals
• Delayed care, which erodes member satisfaction
• Poor outcomes, increasing downstream associated medical costs

The takeaway? Staffing for UM must prioritize clinical competency, not just volume. Plans should consider right-skilling strategies, where automation handles routine tasks and clinicians focus on complex cases requiring judgment.

Governance and Compliance: Non-Negotiable Standards

Health plans operate under strict regulatory frameworks. CMS-0057 mandates rapid turnaround times, while URAC and NCQA require documented oversight, licensure verification, and adherence to timeliness standards. These requirements shape staffing models:

• Licensure alignment: Nurses and physicians must be credentialed for the states they serve
• Oversight structures: Clinical review teams need governance protocols to ensure consistency
• Scalable resources: Plans must anticipate seasonal volume spikes without compromising compliance with the turnaround time and service level

Ignoring these factors can lead to penalties, reputational damage, and member dissatisfaction. A robust staffing plan should integrate compliance checkpoints into daily workflows.

Technology as an Enabler — Not a Replacement

Legacy UM systems often create fragmented workflows and administrative burden, fueling staff burnout. While AI and automation can streamline routine tasks — such as eligibility checks or documentation — they cannot replace clinical judgment. The most effective approach is “human in the loop”:

• Automation for routine tasks: Free up clinicians for complex cases.
• Electronic clinical decision support such as AuthAI:  Expose medical guidelines to providers during submission, enabling real-time auto-approvals and significantly reduces the volume to manual clinical review.
• Intelligent workflows: Reduce manual data entry and improve provider experience.
• Analytics-driven insights: Identify bottlenecks and optimize staffing allocation.

The pitfall? Over-reliance on technology without clinical oversight can lead to inappropriate determinations and compliance risks. Technology should complement — not replace — clinical expertise.

Why Piecemeal Fixes Fail: The Case for a Holistic Strategy

Quick fixes — like hiring temporary staff or layering new tech onto outdated processes — rarely deliver sustainable results. UM transformation requires an integrated approach:

1. Align operational workflows with NCQA and URAC standards and compliance regulations.
2. Deploy decision support technology to streamline information gathering and decision making to accelerate the clinical review process.
3. Robotic process automation: Use automation for administrative tasks and reserve clinicians for exception reviews.
4. Scale operations through insightful analytics to track and report on turnaround and service levels, as well as the waterfall KPIs from prior auth intake, to clinical review, to MD determination–most important to track aging cases.
5. Robust workforce management is critical for ensuring accurate staffing thresholds in predicting and adjusting to seasonality volume changes.
6. At a minimum, a yearly clinical training in new and emerging medical services or technologies, new recommendations for existing treatments, and updates in medical policy or clinical guidelines to increase clinical acumen in medical knowledge and support evidence-based clinical decision making.
7. Phased implementation: Start with high-impact areas, then scale.

This holistic strategy reduces appeals, improves provider trust, and ensures compliance — all while controlling costs. Health plans that embrace this model can transform UM from a cost center into a strategic advantage.

Collaboration for Better Outcomes

UM should be collaborative, not punitive. Peer-to-peer dialogues and integrated care management foster trust and improve patient outcomes. That’s why partnerships matter. Sagility brings operational excellence and staffing agility, ensuring clinical depth and compliance. Availity® delivers a robust platform and network, enabling interoperability and streamlined workflows. Together, we offer a hybrid solution  addressing both sides of the UM equation.

The Bottom Line

Insourcing prior authorization is more than moving work in-house — it’s a strategic transformation. Success hinges on clinical rigor, governance, and technology enablement, supported by a phased, integrated approach. Health plans that get this right will not only meet regulatory requirements but also enhance member experience and provider relationships.

Ready to Reclaim UM? Watch the Webinar!

Join me, Heidi Nielsen, Senior Director of Intelligent Utilization Management at Availity, and and Lydia Turner, Senior Strategy Consultant at PwC, for a dynamic discussion on how leading health plans are modernizing UM by bringing core functions back in-house. Learn how hybrid models, powered by intelligent AI and clinical insight, are helping teams gain control, reduce disruption, and deliver better outcomes.

If you’re leading UM strategy, clinical operations, or digital transformation, this webinar will offer practical insights you can act on.

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