A payer needs to work with plan members and medical providers to influence decisions through...

Utilization Management requirements center on designing Care Request records for authorizations and establishing review workflows across the three standard review types: Prior Authorization, Concurrent Review, and Retrospective Review. Utilization Management structures care requests, authorization review, medical-necessity determination, concurrent review, and related payer-provider approval workflows. From a discovery perspective, the consultant should validate the current-state workflow with the people who perform it, document pain points and handoffs, and translate the findings into functional, data, security, and integration requirements before solution design begins. The remaining options do not directly satisfy the stated requirement; they either address a different functional domain, provide only part of the required behavior, or introduce unnecessary customization compared with the selected Health Cloud approach. This approach also keeps the solution aligned with the standard Agentforce Health data and process model, which is important for maintainability, reporting, interoperability, and consistent user access. In practical terms, the consultant should configure and validate the selected elements (Designing Care Requests to seek authorization from a health plan for drugs, services, and admissions; Considering the Request Review Types; Prior Authorization Review, Concurrent Review, and Retrospective Review) against the scenario ' s acceptance criteria and confirm that the intended users can access the underlying records and functionality.

Study Guide references/topics:Discovery - Utilization Management

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