US Healthcare Essentials

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.