An Overview of Managed Care
(45 CEU Credits)
Course Description When available, this Course will provide an introduction to managed care terminology and issues facing a Medical Services Professiona (MSP) in the managed care setting. It is designed not only as a guide to aid persons who are recently employed in the managed care setting; but also to provide MSP's working in various other settings, i.e. acute care/hospital settings, a better understanding of the many issues dealt with by their counterparts in the managed care world. The program is also a learning tool for those MSPs who are preparing to challenge the CPCS/CMSC certification exams. The course provides a basic knowledge of NCQA Standards and Surveyor Guidelines for managed care and central verification organizations. The program is sponsored and administered by the NAMSS Institute, the educational division of the National Association of Medical Staff Services.
Course Objective: To provide an overview of the principles of managed care including the areas where it interacts with various other healthcare organizations, as well as the various roles played by credentialing specialists in managed care operations.
Learning Outcome:
Upon completion of this course the student should be able to:
- Describe the evolution of the managed care industry in the United States.
- Identify professional organizations and agencies (including acronyms for organization names) associated with managed care and the managed care credentials review process.
- List types of managed care organizations and identify the differences between them.
- Understand the different types of accreditation offered to managed care organizations.
- Outline the qualifications for health network accreditation for NCQA, URAC, and JCAHO.
- Outline the managed care credentialing process for providers.
- Outline the managed care re-credentialing process for providers.
- Identify legal issues/cases important to managed care organizations and credentialing.
- Identify specific issues facing the managed care industry.
- Define terminology relative to managed care.
- Identify the future challenges and opportunities in managed care
Time to Complete 90 days
Who Will Benefit? All individuals with responsibilities and/or working relationships with a managed care organization.
Administration and Management
Medical Terminology
Principles of Medical Staff Organization and Healthcare Finance
An Overview of Accreditation Knowledge
An Overview of Healthcare Law
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