US Healthcare Essentials

Name: US Healthcare Essentials
Rating: 4.5 (8 reviews)

Understanding Insurance, Claims & Healthcare IT

Role Play

Created byManish Nadar

Last updated 2/2026

English

What you'll learn

Understand the US Healthcare System and Key Stakeholders
Explain Health Insurance Plans and Policy Structures
Understand Enrollment and Eligibility Processes
Explain the End-to-End Claims Processing Lifecycle
Analyze Claim Adjudication, Adjustments, and Billing
Understand Medical and Prescription Benefit Management

Course content

5 sections • 14 lectures • 1h 1m total length

Introduction1:32

Overview of the US Healthcare System4:07
Explore how the U.S. healthcare system operates as a mixed model with members, providers, payers, and regulators, detailing enrollment, claims, data exchanges, and the business rules behind system requirements.
Healthcare Industry Stakeholders3:59
Identify and map the key us healthcare stakeholders, including members, providers, payers, employers, and regulators, and explain how their interactions drive claims, payments, and compliance.
Market-Driven Healthcare Solutions4:27
Market-driven healthcare solutions respond to demand, competition, and regulations to shape insurance products that meet member needs and address cost trends.

Health Insurance Providers5:02
Identify health insurance providers and their types, commercial, government-sponsored, and employer-based, then explain core operations like product design, enrollment, claims, provider networks, and risk management for IT projects.
Types of Health Insurance Plans4:35
Identify the major types of US health insurance plans—HMO, PPO, EPO, POS, and HDHP—and explain how network rules, referrals, and cost sharing drive eligibility, claims, and reimbursement.
Policy Design Based on Market Requirements4:09
Design policies align with market demand, cost trends, and regulation, shaping premiums, deductibles, copays, and benefits. Translate policy rules into system configurations for claims, enrollment, and eligibility.

Enrollment Process Overview4:57
Explore how enrollment activates health insurance coverage across individual, employer, and government programs, covering the end-to-end workflow: application, eligibility verification, plan selection, premium setup, and activation.
Eligibility Rules and Validation5:38
Eligibility rules and validation determine whether a member's claim gets paid, guiding claims adjudication beyond enrollment. Key rules include coverage dates, plan eligibility, dependent status, employment status, and network validation.
Common Enrollment Challenges5:24
Identify and mitigate common enrollment challenges in healthcare systems, including data validation errors, date logic issues, late updates, dependent eligibility, and integration failures, to protect claims and billing accuracy.

Requirements

Desire to learn

Description

Understanding the US Healthcare domain is critical for Business Analysts and IT professionals working with insurance companies, healthcare providers, and healthcare IT systems. This course is designed to give you practical, job-relevant domain knowledge, not just theory.

Starting with a clear overview of the US Healthcare system, you’ll understand how different stakeholders—insurance providers, members, providers, and regulatory bodies—interact within the ecosystem. You’ll learn where Business Analysts fit into this landscape and how domain knowledge directly impacts requirements gathering, solution design, and stakeholder conversations.

The course then deep-dives into Health Insurance fundamentals, explaining how insurance plans are structured, how policies are designed based on market needs, and how insurance companies compete through benefit design. This knowledge is essential for understanding real-world project requirements in payer organizations.

You’ll gain hands-on understanding of Enrollment and Eligibility management, including how members are enrolled, how eligibility is validated, and common challenges faced in enrollment systems. From a Business Analyst perspective, you’ll learn how these processes translate into system rules and functional requirements.

A major focus of the course is Claims Processing, where you’ll explore the complete claims lifecycle—from submission to adjudication, adjustments, billing, and payments. You’ll also be introduced to industry standards such as EDI 837, helping you connect business processes with healthcare IT systems.

The course further covers Medical and Prescription Benefits, including how benefits are defined, validated, and managed, as well as the role of Pharmacy Benefit Management (PBM). This section helps you understand how benefit logic impacts claims and member experience.

By the end of this course, you will be able to confidently:

Understand end-to-end US Healthcare insurance processes
Speak the healthcare domain language in projects and interviews
Connect business processes with healthcare IT systems
Add strong healthcare domain value

Who this course is for:

Business Analyst
Healthcare Business Analyst
Junior Business Analyst
Associate Business Analyst
IT Business Analyst
Systems Analyst
Scrum Master (Healthcare Teams)
Product Owner (Healthcare Products)
Project Manager (Healthcare IT)
Software Engineer working on Healthcare Systems

US Healthcare Essentials

What you'll learn

Explore related topics

Course content

Introduction1 lecture • 2min

Introduction to US Healthcare Domain3 lectures • 13min

Health Insurance Fundamentals3 lectures • 14min

Enrollment and Eligibility Management3 lectures • 16min

Benefits and Prescription Management5 lectures • 17min

Requirements

Description

Who this course is for: