Course Information

This course is part II of an advanced course in case management with a comprehensive focus of study on the roles and the applications of professional Case Manager practice. Throughout this course students will examine in-depth information related to the many roles of the professional Case Manager and how they integrate their roles into many different models of case management practice today. Emphasis is on examining models of professional case management with Case Manager Applications of practice including theory and process. Students will be able to comprehend not only the role of the Case Manager but also the applications of professional practice in a wide variety of care settings. Students will examine key learning concepts such as reimbursement resources and challenges while practicing case management and financing of client’s medical benefits. Students will study health care reimbursement in both the private sector and the employer sector. Also examined are group medical plans, HMO’s, PPO’s and Point of Service Plans. Disability Plans, traditional and self-funded insurance plans and riders to life insurance policies are presented. A study of the case manager’s role in working with claims departments is presented as well. In this course we examine key leadership and management roles of the case manager in the practice of professional case management and the key skills and knowledge needed in todays challenging health care environment. New strategies for leading a case management department are examined as well. Students will study Predictive Modeling and Case Stratification and implications for their use in professional case management practice. Also examined in this course are: new characteristics of today’s health care system, the case manager’s role in the era of value-based health care, and new case management and healthcare provider approaches for managing the high-risk and high-cost patients. Students will then examine and study key topics focused on current challenges and emerging trends in case management which include: the aging population, medical advancements, dying in America, medication management, pain management, multiculturalism, health literacy, obesity, models of behavioral health in primary care, healthcare technology and trends, transformative healthcare approaches for the Millennial Generation and the ACA and its implications for case management practice. Students will use a textbook and will also be viewing selected Videos for this course. Course Code: CM 565. Contact hours of education = 25.

Level of Complexity: Advanced

Pre-requisites: This course is particularly designed for those who would like to apply for Fellowship certification as a “Fellow” in the American Academy of Case Management. Pre-requisite to enter this course: must be an RN, Physician, Social Worker, Behavioral Health Specialist, or employed currently as a Case Manager or Utilization Review Specialist in a health care setting. Others may be granted access after individual review and consideration by the Administration of the American Academy of Case Management

Note: you must have successfully completed the following course before enrolling: CM 545: The Case Manager: Roles and Applications I.

Course Refund & AIHCP Policies: access here

Instructor/Course Author: Dominick L. Flarey, Ph.D, MBA, RN-BC, ANP-BC, FACHE

Link to Resume: access here
Email: info@aihcp.org

BOARD APPROVALS: The American Institute of Health Care Professionals, Inc. is a licensed Continuing Education Provider in the State of California, Board of Registered Nursing, Provider # CEP 15595. This course is approved for 25 contact hours of continuing education by the California Board of Registered Nursing. Access information

This course, which is approved by the Florida State Board Of Nursing (CE Provider # 50-11975) also has the following Board of Nursing Approvals, for 25 contact hours of CE

The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the Arkansas Board of Nursing. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the Georgia Board of Nursing. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the South Carolina Board of Nursing. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the West Virginia Board of Examiners for Professional Registered Nurses. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the New Mexico Board of Nursing. CE Provider # 50-11975.

TEXTBOOK: There is one required Textbook for this course.

The Case Manager’s Handbook, 6th Edition. By: Catherine M. Mullahy. Jones & Bartlett Learning. New York: 2017. ISBN#: 9781284102406.

Link to Purchase on Amazon.com: click here

GRADING: You must achieve a passing score of at least 70% to complete this course and receive the 25 hours of awarded continuing education credit. There are no letter grades assigned. You will receive notice of your total % score. Those who score below the minimum of 70% will be contacted by the American Institute of Health Care Professionals and options for completing additional course work to achieve a passing score, will be presented.

TIME FRAME: You are permitted two years from the date of enrollment, to complete this course. There are no other set time-frames, other than the two year allotted time. If you do not complete the courses within the two-year time-frame, you will be removed from the course and an “incomplete” will be recorded for you in our records. Also, if you would like to complete the courses after this two-year expiration time, you would need to register and pay the course tuition fee again.

COURSE OBJECTIVES: 

Upon completion of this course, you will be able to:

1. Discuss the primary reimbursement resources that are used today in our health care system
2. Define who the basic insurance and administrative company players are in the reimbursement systems
3. Discuss how case managers and employers respond to health care costs today
4. Define and discuss Employer-Sponsored health benefit insurance
5. Define and discuss Private Indemnity health benefit plans
6. Define and discuss Medical Plans: HMOs, PPOs, and POS plans
7. Define and discuss short-term and long-term disability insurance plans
8. Define and discuss Consumer-Driven Health Care Plans
9. Define and discuss Diagnosis-Specific Benefits
10. Define and discuss Traditional Insurance Plans
11. Define and discuss Self-Funded Insurance Plans
12. Define and discuss Stop-Loss Insurance Plans
13. Discuss Viatical Settlements
14. Discuss Riders to Life Insurance Policies
15. Understand the role of the case manager in coordination of benefits
16. Examine new directions in Public Sector Case Management
17. Discuss the role of a case manager in the public sector
18. Define and discuss the challenges for case managers in the public sector
19. Discuss Military case management
20. Define and discuss the case manager’s role in working with Claims Departments
21. Discuss the process of Outcomes Management with analysis of Financial and Quality Assurance reporting
22. Define the key nuances between negotiating with providers and payers
23. Discuss negotiating in a managed care environment
24. Define and discuss cost-benefit analysis reports
25. Discuss how to develop cost-benefit summaries
26. Define and discuss key new strategies for leading a case management department
27. Define and discuss Predictive Modeling
28. Define and discuss Case Stratification
29. Understand how Predictive Modeling and Case Stratification have important implications for case management practice
30. Define and discuss the key new characteristics of today’s healthcare systems
31. Discuss the case manager’s role in the era of value-based health care
32. Discuss and understand how measuring clinical outcomes assists in demonstrating a provider’s efficient care
33. Discuss the concept of hospitals entering new risk arrangements with payers
34. Discuss the role of the case manager in value-based models
35. Understand healthcare price transparency
36. Define, discuss and understand new case management and healthcare provider approaches for managing high-risk and high-cost patients
37. Discuss Informatics and Transitions of care for complex, chronically ill patients
38. Discuss Medicaid Health Homes
39. Discuss the aging population and new case management considerations for this population
40. Discuss the key concepts and issues related to dying in America and how they related to the practice of case management
41. Discuss medication management and define the key issues that are implicated in case management practice today
42. Define and discuss pain management and the key issues for the role of the case manager in case management practice today
43. Discuss multiculturalism and the key challenges it presents to case managers in practice today
44. Define and discuss Health Literacy and the issues and challenges in presents in case management practice
45. Discuss Obesity as an epidemic and treatment issues in case management practice
46. Define and discuss an Integrated Model of Behavioral Health Care in Primary Care and its opportunities for case manager practice
47. Discuss current health care technology and trends and implications for case managers
48. Discuss transformative healthcare approaches for the Millennial Generation
49. Discuss the Affordable Care Act of 2010 and its implications for case managers

COURSE CONTENT

• Reimbursement and resource challenges in case management
• Employers and case managers responses to costs
• Private sector health care reimbursement
• Employer sector health care reimbursement
• Group Medical Plans, HMOs, PPOs, POS Plans
• Disability Insurance Plans
• Consumer-Driven Health Care Plans
• Diagnosis-Specific Health Care Plans
• Traditional Insurance Plans
• Self-Funded Insurance Plans
• Stop-Loss Insurance Plans
• Viatical Settlements
• Riders to Life Insurance Policies
• Coordination of health benefits
• Funding sources for Public Sector health benefits
• The case manager in the public sector
• Military Case Management
• Claims Departments structure and operations
• Case managers roles in working with claims departments
• Outcomes Management with analysis of financial and quality assurance reporting
• Negotiating skills for case managers
• Nuances between negotiating with Providers and Payers
• Negotiating in a managed care environment
• Cost-Benefit Analysis Reports
• Cost-Benefit Analysis Summaries
• Quality Assurance Programs
• Feedback from Patients
• New strategies for leading case management departments
• The difference between leadership and management
• Evaluating a case management department
• Business considerations for a case management department
• Recruiting and hiring case managers
• Predictive Modeling
• Case Stratification
• New Characteristics of today’s health care systems
• Hospital consolidations
• The Case Manager’s role in the era of value-based health care
• Measuring clinical outcomes
• Evaluating a providers efficiency of care
• The role of case managers in value-based models
• Healthcare price transparency
• New case management approaches for managing high-risk/high-cost patients
• New healthcare provider approaches for managing high-risk/high-cost patients
• Population Health Management
• Informatics and Transitions of care
• Medicaid Health Homes
• Complex Care Management Models of Care
• The Aging Population and new case management considerations
• Medical advancement and new case management considerations
• Dying and America and case management considerations
• Medication management and implications for case management practice
• Pain management and the role of case managers
• Our Nation’s Multiculturalism and challenges for case managers
• Health Literacy and adherence issues
• Obesity our new epidemic
• Behavioral Health with Primary Care
• Healthcare Technology and Trends and implications for case managers
• Transformative Healthcare and approaches for the Millennial Generation
• The Affordable Care Act of 2010 and implications for case management practice