Overview
This impressive career credential positions you as a seasoned healthcare management professional versant in a range of specialties, including care management, financial management, network development, maintenance strategies, medical policies, governance, policy trends, and more.
Required Courses
- Healthcare Management: An introduction (AHM250)
- Governance, Legal Issues, Medicare and Medicaid (AHM510)
- Health Plan Finance and Risk Management (AHM520)
- Network Management (AHM530)
- Medical Management (AHM540)
Learning Outcomes
Achieving this designation demonstrates to your colleagues, partners, and clients that you have a strong commitment to the industry and your organization’s success.
Course Outline
- 1.1: Gain a practical understanding of the evolution of health care delivery and financing from pre-paid plans to ACOs
- 1.2: Understand the basic concepts of health insurance provider organizations
- 1.3: Distinguish among HMOs, PPOs, POSs, and managed indemnity
- 1.4: Recognize HSAs' and HRAs' roles in today's consumer-centric environment
- 1.5: Identify different types of health insurance provider organizations
- 1.6: Learn the importance of network structure and management in delivering quality healthcare
- 1.7: Examine the interplay of information technology with essential functions of health insurance provider operations
- 1.8: Explore the concepts of rating, underwriting, and claims administration in health insurance provider environments
- 1.9: Delve into legislative and regulatory issues affecting the health insurance industry, including the Affordable Care Act (ACA) and the 21st Century Cures Act
- 1.10: Understand role of government-sponsored programs, including Medicare and Medicaid, in providing coverage to large segments of the population
- 1.11: Review relevant terms, industry issues, care scenarios, and concepts
- 2.1: Explore factors shaping the health insurance industry, its formation, types of insurance, and structure
- 2.2: Understand how health insurance providers use reorganization, reengineering, and strategic planning to improve performance
- 2.3: Examine legal issues faced by health insurance providers in a post-reform environment
- 2.4: Understand the legal issues surrounding ERISA, pharmacy benefits, and wellness
- 2.5: Delve into federal and state regulatory requirements that affect health insurance providers
- 2.6: Learn the role of the federal government as a purchaser of health care benefits
- 2.7: Dig deep into the role of health insurance providers in providing services to both Medicare and Medicaid enrollees
- 2.8: Analyze how fraud and abuse affect health care's cost and quality
- 2.9: Explore how health insurance providers use organizational control systems to build internal structures that meet external demands for accountability
- 2.10: Review relevant terms, industry issues, case scenarios and concepts
- 3.1: Analyze the role of strategic financial planning in setting a health insurance provider's future direction
- 3.2: Gain an understanding of risk, decisions regarding risk assumption, and how health insurance providers control risk
- 3.3: Compare the difference between stop-loss insurance and stop-loss reinsurance from the perspective of health insurance providers
- 3.4: Learn about the financial risks for health insurance provider organizations that provide health care services to Medicare and/or Medicaid populations compared to risks within the commercial population
- 3.5: Distinguish between fully funded and self-funded plans and the increasing role of self-funding in the marketplace
- 3.6: Discover how to identify claim related components of health insurance providers' financial statements
- 3.7: Recognize different reserving methodologies used by health insurance providers
- 4.1: Gain a detailed understanding of the scope and organization of the network management function within health insurance provider organizations
- 4.2: Understand how network strategies improve access, quality, and cost-effectiveness
- 4.3: Learn the process for network provider selection
- 4.4: Master the essential elements of a contractual relationship between health insurance providers and health care providers
- 4.5: Identify the primary responsibilities and obligations of health insurance providers and health care providers under a provider contract
- 4.6: Map out how health insurance providers select, contract with, and compensate specialists and health care facilities
- 4.7: Recognize special requirements that affect network management for Medicare, Medicaid, and workers' compensation networks
- 4.8: Explore how health insurance providers ensure their provider networks remain adequate to meet member needs
- 5.1: Understand role of medical management in health insurance provider organizations
- 5.2: Identify how and why a delegation is used in medical management
- 5.3: Examine the role of medical management in providing pharmacy services
- 5.4: Recognize the importance of preventive care and self-care programs
- 5.5: Explore strategies for managing complex individual cases
- 5.6: Understand disease management-its purpose, processes, and programs
- 5.7: Learn how medical management is used in different types of care
- 5.8: Quality management methods-measurement and improvements
- 5.9: Recognize how medical management is used to deliver Medicare and Medicaid services
