U.S. Utilization Management Solutions Market Size, Share & Trends Analysis Report By Type (Standalone Solutions, Integrated Solutions), By Mode Of Delivery (Cloud-based, On-premise), By Component (Software, Service), By End Use, And Segment Forecasts, 2025 - 2030

Market Size & Trends

The U.S. utilization management solutions market size was estimated at USD 613.15 million in 2024 and is projected to grow at a CAGR of 9.9% from 2025 to 2030. Factors such as reinventing utilization management (UM) to bring value to point-of-care providers, increasing demand for technologically advanced UM solutions, growing adoption of utilization management by various organizations, and increased strategic partnerships & collaboration deals are expected to boost the market. For instance, in January 2024, ZeOmega collaborated with Datycs to automate healthcare data workflows and digitize faxed documents.

The rise in investments in UM solutions reflects significant advancements in healthcare technology and a shift toward value-based care, where efficiency, patient satisfaction, and outcome-oriented approaches are prioritized. Increasing investments generate valuable opportunities for UM. For instance, in July 2024, the Medical Review Institute of America (MRIoA), a provider of UM review solutions for payers, secured funding from Parthenon Capital, while existing investors and MRIoA management retained substantial equity ownership in the company as part of the transaction.

Moreover, U.S. healthcare payers and providers are increasingly prioritizing IT investments, with 75% reporting heightened spending in 2023. Providers are directing these funds toward IT services and infrastructure, including cybersecurity, clinical workflow optimization, claims processing, payments, data platforms, interoperability, care coordination, and Revenue Cycle Management (RCM).

In addition, market participants are engaging in various strategic initiatives such as mergers and acquisitions, new product launches, and geographic expansion that foster market growth. For instance, in June 2024, Evolent Health, Inc. announced its agreement to acquire specific assets from Machinify, which include the Machinify Auth team, AI-driven utilization management products, and associated software applications.

The COVID-19 epidemic significantly impacted the U.S. utilization management solutions industry, speeding the acceptance of digital tools and automation to address increased healthcare demand. Hospitals and insurers faced challenges such as remitted optional procedures, rising specialty medicine costs, and a surge in outpatient and critical care applications. In response, there was a notable shift towards cloud-based UM platforms, telehealth integration, and robotic process automation (RPA) to streamline previous authorizations and care collaboration. These changes were driven by the need to enhance effectiveness, reduce executive burdens, and address workforce shortages, particularly among physicians and nurses. The epidemic underlined the significance of flexible and scalable UM results in maintaining care quality and functional sustainability.

Market Concentration & Characteristics

The chart below illustrates the relationship between market concentration, industry characteristics, and industry participants. The x-axis represents the level of industry concentration, ranging from low to high. The y-axis represents various industry characteristics, including industry competition, impact of regulations, level of partnerships & collaborations activities, degree of innovation, and regional expansion. For instance, the market is slightly fragmented, with many product & service providers entering the market. The degree of innovation, the level of partnerships & collaboration activities, and the impact of regulations on the industry are high. However, the regional expansion observes moderate growth.

The degree of innovation in the industry is high. The market is experiencing significant innovation as numerous players introduce new products characterized by rapid advancements in technologies such as artificial intelligence, and data analytics for which enhance predictive analytics and optimize care pathways.Further,the seamless integration of UM solutions with electronic health records (EHR) systems facilitates real-time data sharing, improving care coordination and streamlining administrative processes. For instance, in February 2024, Iodine Software launched AwareUM, a solution designed to streamline utilization management and enhance hospital revenue integrity. This launch underscores Iodine's ability to leverage AI, optimize clinical resources, and automate workflows previously seen as reliant on human judgment. These innovations allow healthcare providers to enhance decision-making, reduce administrative burdens, and improve patient outcomes.

The level of partnerships & collaboration activities by key players in the industry is high.Partnerships between tech companies and healthcare providers are fostering innovation. For instance, in June 2024, Cohere Health, a clinical intelligence provider, collaborated with Medical Mutual, an Ohio-based health insurance company, and Rhyme, an EHR-integrated prior authorization automation firm, to transform UM processes. As the landscape evolves, emerging players are positioned to disrupt traditional models, prompting established firms to innovate and adapt to maintain competitiveness.

The impact of regulations on the market is high. Regulations such as the U.S. Health Insurance Portability and Accountability Act (HIPAA) was established to safeguard healthcare data. Non-compliance with these regulations can lead to severe legal consequences and financial penalties for both UM providers and healthcare facilities. Breaches of patient data, whether accidental or due to malicious attacks, can expose highly sensitive information, undermining trust between patients, providers, and payers 

The level of regional expansion in industry is moderate. Increasing demand for UM solutions in the developing U.S., owing to the robust investments in healthcare IT, technological innovations, and potential improvements in market practices and regulatory compliance. 

Case Study:

Revamping Utilization Management Operations for a National Health Plan

Challenge:

A national health plan’s Utilization Management (UM) department was underperforming due to siloed operations, a lack of experienced leadership, an absence of a quality oversight function, and poor data management. These issues led to duplicated efforts, regulatory non-compliance, and compromised patient care.

Solution:

Toney Healthcare restructured the UM, Care Management (CM), and Behavioral Health (BH) departments to improve integration and coordination. They established a quality department, implemented standardized policies and procedures, improved staffing with experienced clinical leaders, and provided training on MCG guidelines. Data reporting processes were also enhanced to support informed decision-making.

Outcome:

The health plan achieved streamlined operations, regulatory compliance, improved staff and provider satisfaction, and better member health outcomes. Utilization Management became a key enabler of high-quality, efficient, and compliant care delivery.

Component Insights

Based on component, the software segment led the market with the largest revenue share of 67.84% in 2024, and is anticipated to grow at the fastest CAGR during the forecast period. Software solutions are expected to grow rapidly as healthcare providers and payers adopt technologically advanced systems to collaborate on a common platform. This allows for a real-time, standardized view of a patient's medical needs, making it possible to automate decisions regarding the Level of Care. For instance, in February 2024, Iodine Software introduced AI-based AwareUM, a solution developed to streamline UM for hospitals.

The services segment is expected to witness at the fastest CAGR during the forecast period, driven by a heightened focus on patient-centric care and the need for efficient healthcare management. As providers aim to improve outcomes while managing costs, the demand for comprehensive services such as consulting, training, and implementation support has surged. 

Type Mode

Based on type, the integrated segment accounted for the largest market revenue share in 2024 and is anticipated to grow at the fastest CAGR during the forecast period. The segment's growth is driven by the increasing focus on technological, the rising need for streamlined and efficient healthcare processes, and evolving regulatory requirements. For instance, Optum focuses on advanced, integrated solutions that streamline care and claims management.

Companies are increasingly leveraging partnerships to expand their reach and improve outcomes. For instance, in October 2022, Cohere Health expanded its partnership with Humana Inc., using Cohere’s digital UM platform for cardiovascular and surgical services. This platform enables seamless prior authorizations and automates clinical intelligence, streamlining patient care journeys while reducing administrative burdens. The solution was deployed across the U.S. in January 2023 for Humana's Medicare Advantage members and employees.

Mode of Delivery

Based on mode of delivery, the web/cloud-based segment accounted for the largest revenue share in 2024 and is expected to grow at the fastest CAGR during the forecast period. Web-based solutions are becoming increasingly popular due to their ease of deployment and affordability. Unlike on-premises solutions, web-based solutions enable healthcare organizations to offer scalability, manage processes remotely, are cost-effective, and seamlessly integrate with existing healthcare systems. This has led to the rising adoption of web-based solutions over on-premises solutions.

Further, healthcare organizations are investing in advanced technologies to improve care quality while managing costs more effectively. For instance, in June 2024, AssureCare expanded its strategic partnership with a major Blues Plan by introducing Akumen, a platform designed to revolutionize healthcare analytics and management for risk-bearing entities, including payers. Akumen specifically addresses the critical needs of payers by enhancing business operations in UM and Care Management (CM).

End Use Insights

Based on end use, the healthcare providers segment led the market with the largest revenue share of 56.5% in 2024 and is expected to grow at the fastest CAGR during the forecast period. Healthcare payers are increasingly adopting utilization management solutions due to their benefits, such as faster authorizations, integration of EHRs for real-time patient data monitoring, and adoption of value-based models. 

AI and predictive analytics are transforming UM by enabling healthcare organizations to anticipate patient needs and optimize workflows. The integration of AI allows for more efficient management of resources and improved patient outcomes. This trend is gaining momentum, with numerous new products being launched that incorporate these technologies. 

Key U.S. Utilization Management Solutions Company Insights

The market is highly fragmented, with many small and large players operating in this space. Strategies such as new product launches and partnerships are playing a key role in propelling market growth. Some of the emerging players in the market are Amalgamated Medical Care Management, IODINE SOFTWARE, Agadia Systems, Inc., Vital Data Technology

Recent Developments

• In June 2024, AssureCare announced the expansion of its strategic partnership with a major Blues Plan, introducing Akumen-a platform aimed at revolutionizing healthcare analytics and management for risk-bearing entities, including payers. Akumen targets the critical needs of payers, enhancing its business operations in both Utilization Management (UM) and Care Management (CM).

“Introduction of Akumen emphasizes our commitment to innovate technology to enhance patient outcomes, improve operational efficiency, and support the unique needs of healthcare providers.”

- Dr. Yousuf Ahmad, President & CEO of AssureCare.

• In January 2024, ZeOmega partnered with Datycs to digitize faxed documents and automate healthcare data workflows. This collaboration with the Clinical AI/NLP company helps health plans streamline prior authorization processes and gain deeper insights into utilization & operational efficiencies.

"This partnership with Datycs supports ZeOmega's mission to provide our clients with the latest, most efficient tools to meet their goals across the care management spectrum”.

- Tony Sheng, VP, Interoperability Solutions, ZeOmega.

• In August 2023, AssureCare introduced OptimAIzer: An AI-powered platform transforming healthcare. OptimAIzer enhances efficiency, effectiveness, and satisfaction for payers, providers, & patients alike.

“OptimAIzer alleviates the burden on physicians by enabling them to make real-time, informed decisions and intelligent recommendations. This solution revolutionizes UM operations by reducing costs while optimizing efficiency, not to mention improving patient and member satisfaction due to a much-expedited medical review process.”

- Dr. Yousuf Ahmad, visionary CEO of Assurecare.

• In April 2022, Change Healthcare launched InterQual 2022, the latest version of its flagship clinical decision support solution, designed to deliver up-to-date evidence-based care recommendations for appropriate care delivery.

• In August 2021 Kroger Health and AssureCare launched a patient-centered integrated care platform for payers, providers, and pharmacies.

“Healthcare delivery is very disconnected in this country. The AssureCare platform can change this by connecting patients, providers, and health insurers. It allows our teams to deliver industry-leading clinical services by combining data assets from multiple sources to deliver the right care to the right patient at the right time.”

- Colleen Lindholz, President of Kroger Health.

U.S. Utilization Management Solutions Market Report Scope

U.S. Utilization Management Solutions Market Report Segmentation

This report forecasts revenue growth at country levels and provides an analysis of the latest industry trends in each of the sub-segments from 2018 to 2030. For this study, Grand View Research has segmented the U.S. utilization management solutions market report based on the product, delivery mode, component, and end use:

• Type Outlook (Revenue, USD Million, 2018 - 2030)

  • Standalone Solutions

  • Integrated Solutions

• Components Outlook (Revenue, USD Million, 2018 - 2030)

  • Software Solutions         

  • Services

• Mode of Delivery (Revenue, USD Million, 2018 - 2030)

  • Web/Cloud-Based

  • On-Premise

• End Use Outlook (Revenue, USD Million, 2018 - 2030)

  • Healthcare Providers

  • Healthcare Payers

  • Other End Use