utilization-management
(5)
Evolent
The company betting that the most expensive corner of American medicine - cancer, cardiology, and back surgery - can be run better when the people paying for care and the doctors delivering it are finally pulling in the same direction.
Alaffia Health
Alaffia Health is a New York-based healthtech company that uses agentic AI paired with expert clinicians to help health insurers detect and stop waste, fraud, and abuse in medical claims. Its Autodor platform forensically reviews complete patient medical records against submitted claims to power payment integrity, utilization management, and appeals workflows - reviewing complex facility claims up to 20x faster than manual processes while keeping humans in the loop for defensible, explainable outcomes.
Ethermed
Ethermed is a Philadelphia-based health technology company that uses large language models and clinical reasoning to automate prior authorization - the paperwork-heavy approval process between healthcare providers and insurers. Its platform intercepts physician orders, gathers documentation, compares payer guidelines, fills forms and submits requests with an audit trail, cutting approval times from days to minutes. Founded in 2021 by Dan Friedman and Michal Such, the company raised an $8.5M Series A in April 2026, bringing total funding above $15M.
Acentra Health
Acentra Health is a McLean, Virginia healthcare technology and clinical services company formed in 2023 from the merger of CNSI and Kepro. It builds Medicaid and Medicare systems, care management platforms, and quality-oversight services for state and federal government health programs, combining public-sector software with clinical staff who review authorizations, assessments, and appeals. Backed by The Carlyle Group, it employs roughly 3,300-3,400 people across the U.S. and India.
basys.ai
basys.ai is a Cambridge, Massachusetts healthcare technology company that builds enterprise-grade, domain-specific AI for health plans and payers. Founded in 2022 by Harvard health data science alumni Amber Nigam and Jie Sun, the company automates prior authorization, utilization management, and payment integrity, turning a process that can take days into decisions rendered in minutes - with plain-language rationales and hyperlinks to the exact policy criteria and clinical notes behind each decision. The platform is designed to encode a payer's own coverage policies so it can compare them against a patient's longitudinal record without requiring integration marathons or sensitive data handoffs.