1. Medical Claims and Provider Network Administration Ensure cost sustainability through efficient claims adjudication and network contracting Improve transparency in pricing, contracting, and utilization data Maintain a comprehensive, affordable, and high-quality provider network Provide flexible plan designs and tools to support effective benefit offerings Maintain a highly accurate provider lookup tool Implement value-based contracts, including site-of-service and specialty pharmacy arrangements Support medical pharmacy oversight, including: o Custom formulary administration o Manufacturer copay assistance integration o Customized preferred infusion networks Coordinate with all vendors (e.g., advocacy, pharmacy, PCI) for seamless member navigation Provide timely and accurate implementations for new Partnership groups and detailed disruption reports Facilitate advanced provider tools (e.g., PA, benefit, and claims data sharing)
