Medical Claims Examiner or Claims Officer Training and Development Needs

Prepared By Solomon Sawerh PetteyOrganisation Osu Klottey NHIS Location Osu, Accra Ghana Medical Claims inspector orClaims Officer training & ontogenesis INTRODUCTION Significant achievements capture been do at arresting potential claim related challenges which threatened NHIS sustainability, only if the claims still continue coming in fast with increased invent load. The uses of technology and claim officers to effectively manage claims also continue to provoke with meaningful results.This document therefore aims to use a scientific focussing approach to steady down the training and development needs of claims officers, which can make headway enhance the effective and efficient management of claims. Case in signalise Claims officers need to have certain knowledge, skills and abilities to examine medical claims effectively. The question is what is the circulating(prenominal) capacitance gap of knowledge, skills and abilities? The work of medical claim examination and approving 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 introductory 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 subject matter 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 companys strategic goals. Approach Benchmarks Challenge of expenditure Traditional methods versus JUST-IN-TIME training and development for practical knowledge Continuum of learning/E-learning Tai lored Programs / wellness Insurance educate Institutions / International AssociationsSAMPLE CONTENT TRAINING AND DEVELOPMENT ACTIVITY PROGRAM (P) rudimentary outline of programs which can be designed to prepare participants to meet the challenges of health care revenue cycle management including amends reimbursement and accounts receivable management, with industrial-strength emphasis on clinical knowledge needed to analyze the field 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 constabulary, case law, and common law as they pertain to claim political science. P 4, Claim Administration administration of cla ims under health insurance contracts (both individual and group), including investigation and cost retain 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 redevelopment marketing principles and functions, customer service concepts and strategies as integral aspects of health insurance Foundations of Excellence Details/courses Anatomy and Physiology and entre to Human Disease initiation Techniques, Advanced Composition, Diversity in Society Foundations of Health Professions Applied reading Technology Medical Terminology and Introduction to Health Careers Major be Foundations Administrative Procedures or Medical Office Applications Health Record study Health Care Management Foundations Procedural and Diagnostic Coding Introduction to Health Care Reimbursem ent Systems and Reimbursement Applications Claims Management Practicum Health Care Law and moral philosophy