Job Title: Manager – TPA & Cashless Operations
Department: Billing
Reporting To: Hospital Director
1. Job Objective
To serve as the primary point of contact for all insurance-related matters, ensuring a seamless cashless treatment experience for patients while maintaining 100% accuracy in claim processing and timely reimbursement for the hospital.
2. Key Responsibilities
- TPA & Private Insurance: Manage the entire lifecycle of private insurance claims, from checking policy validity and initiating Pre-Authorization to resolving queries and final discharge processing.
- PMJAY (Ayushman Bharat) Management: Act as the lead coordinator for the PMJAY scheme. This includes patient identification, Package Blocking, uploading clinical evidence on the TMS portal, and ensuring successful claim submission.
- Liaison & Empanelment: Maintain professional relationships with TPA executives and Insurance companies. Assist the management in the renewal of empanelment contracts.
- Query Handling: Coordinate with doctors and nursing staff to provide clinical justifications and additional documents required by insurance companies to prevent claim rejections.
- Claim Settlement & Recovery: Monitor the accounts receivable for the cashless department. Track pending payments and ensure that all settled claims are credited to the hospital bank account within the stipulated TAT (Turnaround Time).
- Patient Counseling: Explain the cashless process, inclusions, and exclusions to patients and their families to ensure transparency and avoid disputes during discharge.
- Audit & Compliance: Ensure all files are documented as per NABH and Insurance regulatory standards.
3. Required Skills & Qualifications
- Education: Graduate in any stream. A Master’s in Hospital Administration (MHA/MBA) or a Bachelor’s in a medical field (BAMS/BHMS/B.Sc Nursing) is highly preferred.
- Experience: 3–7 years of experience in a hospital TPA department, specifically handling both private insurance and government schemes like PMJAY.
- Technical Proficiency: Must be an expert in the PMJAY Portal (TMS) and various TPA web portals. Proficiency in MS Excel for reporting is essential.
- Negotiation Skills: Ability to coordinate effectively with insurance doctors and TPA auditors to justify medical necessity.
4. Performance Indicators (KPIs)
- Percentage of claims approved versus rejected.
- Average time taken to initiate Pre-auth (TAT).
- Reduction in "Discharge to File Submission" time.
- Resolution of pending payments older than 45 days.
Pay: ₹30,000.00 - ₹50,000.00 per month
Work Location: In person
