Utilization management is clinical work.
Medical necessity sits at the intersection of medicine, coverage requirements, healthcare operations and responsible resource use. Our model keeps physician reasoning at the center of that work.
Pankaj Karan, M.D., ABIM
Founder and Medical Director
Dr. Pankaj Karan leads UM Physician Advisors LLC with a physician-first approach to utilization management: apply the appropriate coverage framework and clinical criteria, understand the complete clinical record, and document the reasoning clearly.
His work is centered on physician-level medical necessity and level-of-care review for healthcare organizations, including prior authorization, inpatient and observation review, continued-stay review, retrospective review, appeals, peer-to-peer discussions, and complex case escalation.
Clinical medicine meets utilization management
Utilization management sits at the intersection of clinical medicine, healthcare operations, coverage requirements and responsible resource utilization. Effective review requires more than a checklist—it requires experienced clinical interpretation.
Core areas of physician review
- Prior authorization and medical necessity review
- Inpatient, observation and continued-stay review
- Retrospective review and appeals
- Peer-to-peer physician discussions
- Claims and disputed-service review
- Complex case escalation and clinical quality oversight
Our mission
To provide healthcare organizations with clinically sound, evidence-informed and clearly documented physician review that supports appropriate utilization, consistent decision-making and responsible healthcare operations.
Our values
- Clinical integrity and independent physician judgment
- Consistent, case-specific review methodology
- Clear and defensible clinical reasoning
- Confidentiality and appropriate handling of clinical information
- Practical support for real-world utilization management workflows
The physicians behind the review
Physicians are the core of our review model. Learn how our reviewers approach complex medical-necessity cases and the professional qualities we expect them to bring to each determination.
The Physicians Behind the Review