AHIP Courses - Managed Care and Care Management

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Managed Care and Care Management

Medical Management, Part I (An Overview)

In an easy-to-understand, accessible style, this self-study course gives you a detailed overview of the history and evolution of health care management. You’ll get a clear definition of medical management, with timelines and descriptions of marketplace demands that led to new models for the financing and delivery of health care services. This course will help you identify key initiatives, both public and private, that contributed to medical management, and tools and strategies used to ensure quality, improve access, and manage costs.

What You’ll Learn:

Historical perspectives on the development of health care management
Early models of health insurance and managed care
The definition and drivers of medical management
How legislative and regulatory requirements affect the industry
Where accreditation and certification fit in
Why health care benefit plans emerged
Current trends and demands
Relevant terms, industry trends, case scenarios, and key concepts

Who Should take this Course:

Medical management staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs
Third party administrators
Utilization, quality, case, and disease management professionals
Medical call center managers and staff
Educators at the college level who teach courses in health care administration
Consumers and others in related fields who seek a practical overview of this subject

Enrollment
$155 AHIP Members; $190 Non-members

To enroll in a course, or purchase a text book, please log in, and browse our Center’s online catalog. If you are a new user, please register for an account to get started.

Publication
Medical Management: An Overview
$40 AHIP Members; $50 Non-members

Earn a Designation
This course is good towards earning the following Center designations:

Medical Management Associate (MMA)

Continuing Education Credits

The Commission for Case Manager Certification (CCMC) grants 12 contact hours for this course.

Medical Management, Part II (Utilization Management)

A balancing act among professionals who work for health insurance plans, hospitals, and other entities, utilization management is centered on the needs of the patient to ensure the right provider, treatment, and site for delivery of services. In this course, you’ll examine the many aspects of utilization management to see how it is incorporated into a variety of venues and programs, and why it exists today. This course also discusses successes and failures, clarifies key issues, and looks at the future of utilization management.

What You’ll Learn:

The definition, history, and evolution of utilization management
Form and functions of current practice
How decision support tools are used
The roles of participants
Influences on utilization management activities
Industry standards
Accreditation and certification processes
Relevant terms, case scenarios, and key concepts

Who Should take this Course:

Medical management staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs
Third party administrators
Utilization, quality, case, and disease management professionals
Medical call center managers and staff
Educators at the college level who teach courses in health care administration
Consumers and others in related fields who seek a practical overview of this subject

Publication
Medical Management: Utilization Management
$40 AHIP Members; $50 Non-members

Earn a Designation
This course is good towards earning the following Center designation:

Medical Management Associate (MMA)

Continuing Education Credits

The Commission for Case Manager Certification (CCMC) grants 16 contact hours for this course.

Medical Management, Part III (Call Centers)

Here’s a practical overview of the “telehealth” industry—from standard call centers that serve health insurance plan members to more sophisticated systems that provide access to registered nurses who can assist patients with specific health problems. This course is ideal if you want to learn more about the key role of call centers in integrated care management systems. You’ll get a good look at the nuts and bolts of the business as you examine service and quality issues, the impact of legal and regulatory requirements, and trends in the use of electronic communications by health care consumers.

What You’ll Learn:

The steps to take in establishing a call center
How to select vendors
What to expect with regard to hiring, training, and retaining employees
Issues involving service and quality
The impact of legal and regulatory requirements
Trends in the use of electronic communications by health care consumers
Relevant terms, case scenarios, and key concepts

Who Should take this Course:

Medical call center managers and staff
Staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs who seek more knowledge of integrated care management systems
Technical and business professionals in related fields who want to learn more about the key role of call centers in integrated care management systems
Health care customer service representatives

Earn a Designation
This course is good towards earning the following Center designations:

The Commission for Case Manager Certification (CCMC) grants 12 contact hours for this course.

Publication
Medical Management: Call Centers
$40 AHIP Members; $50 Non-members

Earn a Designation
This course is good towards earning the following Center designations:

Continuing Education Credits

The Commission for Case Manager Certification (CCMC) grants 12 contact hours for this course.

Medical Management, Part IV (Case Management)

Case managers help clients and families navigate health care delivery systems and manage their health care needs. Practitioners come from many disciplines—they are nurses, social workers, rehabilitation counselors, and physicians—and collaborate with other key stakeholders to achieve quality, cost-effective outcomes. This self-study course lets you dig into the basic concepts of case management, find out about the background of the professionals who provide these services, and discover how case management processes and services function in a modern health care environment.

What You’ll Learn:

The definition and basic concepts of case management
The role of the case manager, background of the professionals who provide these services
The case management processes
The organizational structure for delivery of services
Related aspects of case management
Trends in case management
Relevant terms, case scenarios, and key concepts

Who Should take this Course:

Staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs who want to learn more about case management and where it fits in today’s health care systems
Nurses, social workers, and other professionals who are interested in becoming case managers
Case managers who seek more education in this discipline

Publication
Medical Management: Case Management
$40 AHIP Members; $50 Non-members

Earn a Designation
This course is good towards earning the following Center designation:

Medical Management Associate (MMA)

Continuing Education Credits

The Commission for Case Manager Certification (CCMC) grants 16 contact hours for this course.

Medical Management, Part V (Disease Management)

Disease management is a system of coordinated health care interventions in which patient education and self-care are key components. This is an essential course for beginners exploring the concept of disease management as well as managers of full-scale operations. This course makes a complicated subject easy to absorb.

What You’ll Learn:

The definition and basic concepts of disease management
The evolution and current function of coordinated care systems
The description and use of disease management models
The impact of regulation and legislation
Relevant terms, case scenarios, and key concepts

Who Should take this Course:

Staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs who want to learn more about disease management and where it fits in today’s health care systems
Practitioners, program administrators, educators, and other professionals who want to understand the evolution and current practice of disease management

Publication
Medical Management: Disease Management
$40 AHIP Members; $50 Non-members

Earn a Designation
This course is good towards earning the following Center designation:

Medical Management Associate (MMA)

Continuing Education Credits

The Commission for Case Manager Certification (CCMC) grants 12 contact hours for this course.

Medical Management, Part VI (Quality Management)

Providing the right health care at the right time in a way that produces the most favorable patient outcomes is the objective of quality management. This course focuses on the essentials, helping you understand why quality management is important, how programs are implemented, and who the key stakeholders are. You’ll learn the fundamental framework of the practice—programs, processes, and procedures health care organizations use to ensure quality services.

What You’ll Learn:

The definition and basic concepts of quality management
Cost factors and the impact on quality and consumer choice
Who stakeholders are
How to measure quality
Guidelines for patient safety, practice, and performance measures
The essential components of a quality management program
How to ensure the success of a quality management program
Accreditation and its impact on quality
Future trends
Relevant terms, case scenarios, and key concepts

Who Should take this Course:

Employees of health plans and medical groups, including case managers, medical directors, program administrators, who want to learn more about quality management in the health care field
Regulators, purchasers of health care services, educators, and consumers who seek a basic introduction to quality management in the health care setting

Publication
Medical Management: Quality Management
$40 AHIP Members; $50 Non-members

Earn a Designation
This course is good towards earning the following Center designations:

Continuing Education Credits

The Commission for Case Manager Certification (CCMC) grants 16 contact hours for this course.

Healthcare Management: An Introduction (AHM 250)—NEWLY UPDATED

Providing a comprehensive overview, this course will get you up to speed on the basic concepts of healthcare management and its various types of organizational structures. You will learn about major operational areas of health insurance plans as well as legislative, regulatory, and ethical issues that affect the industry.

What You’ll Learn:

The evolution of healthcare delivery in the United States
Basic concepts of health plans
How to distinguish among HMOs, PPOs, POSs, and managed indemnity
The characteristics of health plans for specialty services
Different types of provider organizations
The essential functions and activities within the operations areas of health plans
Concepts of rating, underwriting, financing, and claims administration in health plan environments
Important legislative and regulatory issues affecting the health plan industry
Principal ethical issues confronting health plans

Who Should take this Course:

Employees who work for health care providers or health insurance plans and want to acquire the educational background to pursue a management position in the industry
Case managers and medical directors who seek a broader administrative background
Educators at the college level who teach health care administration
Financial planners, and agents and brokers who specialize in life and health insurance
Medical management staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs
Consumers and others in related fields who seek expertise in this area

Enrollment
$195 AHIP Members; $255 Non-members

To enroll in a course, or purchase a text book, please log in, and browse our Center’s online catalog. If you are a new user, please register for an account to get started.

Earn a Designation
This course is good towards earning the following Academy for Healthcare Management designations:

The Academy for Healthcare Management
This course is brought to you by the Academy for Healthcare Management (AHM). Sponsored by America’s Health Insurance Plans and the Blue Cross Blue Shield Association, AHM relies on both associations’ decades of experience providing continuing education for health insurance plan professionals. AHM serves more than 1,300 health insurance plans caring for and providing coverage to more than 200 million people.

Governance and Regulation (AHM 510)

This course describes the formation, types, and structure of healthcare management organizations. Along with the role of healthcare management in government-sponsored programs, you’ll learn the overall purpose and direction of healthcare management, the impact of fraud and abuse, and the role of public policy.

What You’ll Learn:

Major factors shaping the environment of the health plan industry
How health plans use reorganization and reengineering to improve performance
Key legal issues in health plans
Federal and state regulatory requirements that affect health plans
The role of the federal government as a purchaser of healthcare benefits
How fraud and abuse affect the cost and quality of healthcare
How health plans use organizational control systems to build internal structures that meet external demands for accountability
Methods that health plans and interest groups use to influence healthcare public policy development

Who Should take this Course:

Employees who work for health care providers or health insurance plans and want to acquire the educational background to pursue a management position in the industry
Case managers and medical directors who seek a broader administrative background
Educators at the college level who teach health care administration
Financial planners, and agents and brokers who specialize in life and health insurance
Medical management staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs
Consumers and others in related fields who seek expertise in this area

Earn a Designation
This course is good towards earning the following Academy for Healthcare Management designation:

Fellow, Academy for Healthcare Management (FAHM®)

Health Plan Finance and Risk Management (AHM 520)

Get a comprehensive look at health insurance plan finance. You’ll learn about financial management techniques, funding, risk management, provider reimbursement, plan risk, pricing, underwriting, and rating methods.

What You’ll Learn:

Key accounting principles associated with a health plan's financial information.
Types of risks health plans face and approaches they use to manage them.
Differences between fully funded and self-funded health plans.
Major risks and cost factors associated with the delivery and financing of health-care services under Medicare and Medicaid contracts.
Key factors and methods associated with underwriting and rating healthcare benefits.
Factors health plans consider when developing and pricing healthcare products.
How to analyze and interpret results of a health plan's financial statements through the use of financial ratios.
How to use financial information to develop a health plan's strategic plan and manage the health plan's cash and capital effectively.

Who Should take this Course:

Employees who work for health care providers or health insurance plans and want to acquire the educational background to pursue a management position in the industry
Case managers and medical directors who seek a broader administrative background
Educators at the college level who teach health care administration
Financial planners, and agents and brokers who specialize in life and health insurance
Medical management staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs
Consumers and others in related fields who seek expertise in this area

Earn a Designation
This course is good towards earning the following Academy for Healthcare Management designation:

Fellow, Academy for Healthcare Management (FAHM®)

Network Management (AHM 530)

Learn about the network management function in health insurance plans as this course provides you with insight into both network development strategies (risk management, recruiting, selection and contracting) and network maintenance strategies (managing provider performance and feedback). You’ll also learn about considerations for different types of networks.

What You’ll Learn:

The scope and organization of the network management function in health plans
Network strategies for access, quality, and cost-effectiveness
The process for network provider selection
Essential elements of a contractual relationship between health plans and providers
The primary responsibilities and obligations of health plans and providers under a provider contract
How health plans select, contract with, and compensate specialists and healthcare facilities
Special requirements that affect network management for Medicare, Medicaid, and workers' compensation networks
How health plans ensure their provider networks remain adequate to meet member needs

Who Should take this Course:

Employees who work for health care providers or health insurance plans and want to acquire the educational background to pursue a management position in the industry
Case managers and medical directors who seek a broader administrative background
Educators at the college level who teach health care administration
Financial planners, and agents and brokers who specialize in life and health insurance
Medical management staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs
Consumers and others in related fields who seek expertise in this area

Earn a Designation
This course is good towards earning the following Academy for Healthcare Management designation:

Fellow, Academy for Healthcare Management (FAHM®)

Medical Management (AHM 540)

Explore medical policy and technology evaluation, appropriateness of care issues, authorization systems, and clinical practice guidelines. With this course, you’ll discover focused strategies for utilization management, including clinical paths and disease management. Quality management (QM) methods and strategies are also described. You’ll also learn about accreditation, quality improvement studies, benchmarking, performance measurement, and legal aspects of QM are addressed, as well as QM strategies for different clinical settings.

What You’ll Learn:

The role of medical management in a health plan
How and why a delegation is used in medical management
How health plans develop and implement medical policy
The importance of preventive care and self-care programs
Strategies for managing complex individual cases
Disease management—its purpose, processes, and programs
How medical management is used in different types of care
Quality management methods—measurement and improvement
How medical management applies to government-sponsored programs

Who Should take this Course:

Employees who work for health care providers or health insurance plans and want to acquire the educational background to pursue a management position in the industry
Case managers and medical directors who seek a broader administrative background
Educators at the college level who teach health care administration
Financial planners, and agents and brokers who specialize in life and health insurance
Medical management staff working in hospitals, health systems, HMOs, health insurance plans, and PPOs
Consumers and others in related fields who seek expertise in this area

Earn a Designation
This course is good towards earning the following Academy for Healthcare Management designation:

Fellow, Academy for Healthcare Management (FAHM®)

America's Health Insurance Plans

Quick Links

LEARN. ACHIEVE. SUCCEED.

Managed Care and Care Management

Medical Management, Part I (An Overview)

Medical Management, Part II (Utilization Management)

Medical Management, Part III (Call Centers)

Medical Management, Part IV (Case Management)

Medical Management, Part V (Disease Management)

Medical Management, Part VI (Quality Management)

Healthcare Management: An Introduction (AHM 250)—NEWLY UPDATED

Governance and Regulation (AHM 510)

Health Plan Finance and Risk Management (AHM 520)

Network Management (AHM 530)

Medical Management (AHM 540)

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