Stabilize payer operations, strengthen compliance, and elevate member and provider experience—at scale
Payer Ops Managed Services
Overview
Payers are under pressure to deliver better service with tighter margins while navigating complex regulatory requirements, rising medical cost trends and increasing member expectations. PwC’s Payer Ops Managed Services help health plans modernize and run core operational functions—combining industry experience, tech-enabled delivery, and outcome-focused governance to improve reliability, speed, compliance readiness and cost-to-serve.
Market trends
Capabilities
- Claims operations and payment integrity
- Enrollment, billing and eligibility
- Provider data management and network operations
- Member service, appeals and grievances
- Care management and utilization management operations
- Compliance operations and regulatory readiness
- Digital enablement for advocacy and engagement
Claims operations and payment integrity
Run and optimize claims intake through adjudication, pricing, payment and recovery workflows—reducing rework, cycle time and leakage while improving accuracy and provider experience.
Enrollment, billing and eligibility
Stabilize enrollment and eligibility operations, premium billing and reconciliations to reduce member disruption, improve accuracy, and strengthen downstream service performance.
Provider data management and network operations
Operate provider lifecycle and data quality processes (onboarding, maintenance, directories) to reduce friction, improve network adequacy operations and support better member/provider interactions.
Member service, appeals and grievances
Improve speed and quality of service operations with standardized case workflows, better visibility, and continuous improvement—supporting higher satisfaction and fewer escalations.
Care management and utilization management operations
Support operational workflows that enable clinical programs (e.g., authorizations, care coordination support, documentation) to improve timeliness, consistency and audit readiness.
Compliance operations and regulatory readiness
Operationalize compliance with integrated dashboards, real-time tracking and proactive readiness—addressing the industry reality that most payers are overbuilt yet underdelivering.
Digital enablement for advocacy and engagement
Accelerate advocacy and engagement operations using pre-configured workflows and dashboards (e.g., case management visibility, Member 360 insights) to improve efficiency and effectiveness.
