Medical Claims Examiner or Claims Officer Training and Development Needs

Prepared By: Solomon Sawerh PetteyOrganisation: Osu Klottey NHIS Location: Osu, Accra – Ghana Medical Claims Examiner orClaims Officer| training & development| | | | INTRODUCTION Significant achievements have been made at arresting potential claim related challenges which threatened NHIS sustainability, but the claims still continue coming in fast with increased work load. The uses of technology and claim officers to effectively manage claims also continue to advance with meaningful results.

This document therefore aims to use a scientific management approach to determine the training and development needs of claims officers, which can further enhance the effective and efficient management of claims. Case in Point Claims officers need to have certain knowledge, skills and abilities to examine medical claims effectively. The question is: what is the current capacity gap of knowledge, skills and abilities? The work of medical claim examination and approval are critical and complex and this lends support to the question above.

The research aims to determine the training and development needs of claims officers by examining levels of education, professional background and prior knowledge of claims vetting and ways to determine the impact of training. Focus will be on the claim officers’ perspective of needs, best approach to close capacity gaps, and better enhancement of NHIA activities towards the improving upon the performance of claim officers.

About 70% of NHIS claims have been projected to be processed electronically, but leveraging technology in terms of claims management will not adequately address the capacity deficit, unless the manpower is well equipped to contribute meaningfully towards the rrealization of the company’s strategic goals. Approach Benchmarks Challenge of expenditure Traditional methods versus JUST-IN-TIME training and development for practical knowledge Continuum of learning/E-learning Tailored Programs / Health Insurance Training Institutions / International Associations

SAMPLE CONTENT: TRAINING AND DEVELOPMENT ACTIVITY PROGRAM (P) Basic outline of programs which can be designed to prepare participants to meet the challenges of health care revenue cycle management including insurance reimbursement and accounts receivable management, with strong emphasis on clinical knowledge needed to analyze the content of medical records for optimal reimbursement P 1, Medical Aspects of Claims – describes the anatomy and physiology of the human body, as well as disorders and treatment of the various body systems.

P 2, Basic Pharmacology – introduction to the basic study of drugs, therapeutic uses, dosage and actions. P 3, Health Insurance Law – provide an understanding of the insurance policy as a legal contract – aspects of statutory law, case law, and common law as they pertain to claim administration. P 4, Claim Administration – administration of claims under health insurance contracts (both individual and group), including investigation and cost control techniques.

P 5, Management of Claim Operations – application of management theory to the operations of claim departments, including the management functions of planning, controlling, organizing and leading. P 6, Foundations of Insurance Marketing and Customer Service – marketing principles and functions, customer service concepts and strategies as integral aspects of health insurance Foundations of Excellence| Details/courses| | Anatomy and Physiology and Introduction to Human Disease | | Presentation Techniques, Advanced Composition, Diversity in Society| |

Foundations of Health Professions| | | Applied Information Technology| | Medical Terminology and Introduction to Health Careers| | Major| | | Accounting Foundations | | Administrative Procedures or Medical Office Applications| | Health Record Content| | Health Care Management Foundations| | Procedural and Diagnostic Coding| | Introduction to Health Care Reimbursement Systems and Reimbursement Applications | | Claims Management Practicum| | Health Care Law and Ethics|