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Who should take the AHM-530 exam
- Financial executives working with clients looking to maximize their health dollars
- Medical management employees working in hospitals, health systems, and, health insurance plans
- Case administrators and medical directors who inquire a broader administrative background
- Employees who work for health care providers or health insurance plans and want to get the educational background to proceed with a management position in the industry
- Agents and brokers who expert in life and health insurance
- Teachers at the school level who teach health care administration
Reference: https://www.ahip.org/courses/network-management-ahm530
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- How health plans ensure their provider networks remain adequate to meet member needs
- The primary responsibilities and obligations of health plans and providers under a provider contract
- Network strategies for access, quality, and cost-effectiveness
- Special requirements that affect network management for Medicare, Medicaid, and workers' compensation networks
- Scope and organization of the network management function in health plans
- The process for network provider selection
- How health plans select, contract with, and compensate specialists and healthcare facilities
- Essential elements of a contractual relationship between health plans and providers
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AHIP AHM-530 Exam Syllabus Topics:
| Section | Objectives |
|---|---|
| Provider Contracting and Reimbursement | - Value-based reimbursement models - Fee-for-service, capitation, and bundled payments - Contract negotiation and terms |
| Network Structure and Design | - Types of provider networks (HMO, PPO, POS) - Network configuration strategies - Network adequacy and geographic coverage requirements |
| Utilization and Care Management | - Utilization management tools and techniques - Referral and authorization systems |
| Network Performance and Compliance | - Network performance metrics - Regulatory and accreditation requirements |
| Provider Credentialing and Oversight | - Credentialing and re-credentialing processes - Quality monitoring and performance evaluation |
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