Health Insurance Management

What You Will Learn

• 1 Learn the fundamentals of health insurance, including its purpose, key stakeholders, and risk pooling mechanisms.
• 2 Understand different types of health insurance products such as indemnity plans, HMOs, PPOs, and high-deductible plans.
• 3 Analyze the underwriting process for health insurance, including medical underwriting, community rating, and risk assessment.
• 4 Apply claims management principles, from submission to adjudication, payment, and fraud detection.
• 5 Explore pricing and actuarial methods used to set premiums, reserves, and manage financial solvency.
• 6 Examine the regulatory environment governing health insurance, including ACA, HIPAA, and state mandates.
• 7 Understand provider network management, including contract negotiation, credentialing, and network adequacy.
• 8 Analyze managed care models and their impact on cost containment, quality, and access.
• 9 Evaluate financial statements and key performance indicators specific to health insurers.
• 10 Discover emerging trends such as value-based care, telemedicine, and health insurance exchanges.