Health Insurance Management & Operations Training Course

Course Overview

Learning Objectives

• By the end of this training course, participants will be able to:
• Analyze the structure and operating model of health insurance businesses.
• Evaluate the complete health insurance policy and service lifecycle.
• Assess health insurance operational processes and service delivery requirements.
• Develop effective approaches to policy administration and member management.
• Evaluate health insurance claims processes and operational controls.
• Analyze claims costs, utilization patterns, and major cost drivers.
• Assess medical provider network performance and service quality.
• Apply effective approaches to provider relationship management.
• Improve claims processing efficiency and turnaround times.
• Identify operational, financial, regulatory, and service-related risks.
• Apply appropriate controls to reduce errors, leakage, fraud, and abuse.
• Develop customer service and complaints management practices.
• Establish health insurance operational performance indicators.
• Use operational data to support management decisions and process improvement.
• Strengthen governance and compliance across health insurance operations.
• Develop an integrated health insurance management and operational improvement strategy.

Who Should Attend

Learning Outcomes

• Upon completion of the course, participants will be able to:
• Explain the major functions and operating structures of health insurance organizations.
• Map the health insurance lifecycle from enrollment through renewal and claims.
• Evaluate policy administration and member servicing processes.
• Assess underwriting and eligibility requirements within health insurance operations.
• Analyze claims workflows and identify process improvement opportunities.
• Evaluate claims performance using cost, frequency, severity, and turnaround indicators.
• Assess provider network performance and contractual service requirements.
• Identify sources of medical cost escalation and utilization inefficiency.
• Develop controls for claims leakage, inappropriate utilization, fraud, and abuse.
• Improve coordination between claims, underwriting, providers, finance, and customer service.
• Establish effective customer service and complaints management processes.
• Apply operational risk management and compliance controls.
• Develop meaningful operational dashboards and performance indicators.
• Use data and performance trends to support operational decision-making.
• Identify opportunities for digitalization and process automation.
• Prepare a comprehensive health insurance management and operational improvement plan.

Course Outline