Medical Insurance Operations

What You Will Learn

• 1 Learn the core functions and stakeholders in medical insurance operations
• 2 Understand insurance plan design including benefits, exclusions, and cost-sharing mechanisms
• 3 Apply underwriting principles to assess and price medical insurance risk
• 4 Analyze claims processing workflows, adjudication rules, and payment integrity
• 5 Implement provider network contracting strategies and reimbursement methodologies
• 6 Navigate regulatory requirements, including HIPAA, ACA, and state insurance laws
• 7 Develop proficiency in medical coding systems (ICD, CPT, HCPCS) and billing operations
• 8 Build member management capabilities, including enrollment, eligibility, and customer service
• 9 Identify and prevent fraud, waste, and abuse in medical insurance claims
• 10 Utilize financial metrics such as loss ratio, medical cost ratio, and premium adequacy for performance evaluation