Job Summary
The TPA Executive is responsible for handling cashless hospitalization processes, insurance coordination, patient counseling related to insurance approvals, claim documentation, and communication with insurance companies and Third Party Administrators (TPA). The role ensures smooth processing of pre-authorization, claim settlement, and proper documentation as per hospital and insurance guidelines.
Key ResponsibilitiesInsurance & TPA Coordination
- Coordinate with insurance companies and TPAs for cashless approvals.
- Handle pre-authorization requests and timely submission of required documents.
- Follow up with TPAs/insurance companies for approval status and claim settlement.
- Maintain communication with insurance coordinators and corporate clients.
Patient Handling
- Guide patients and attendants regarding insurance policies, cashless procedures, and documentation requirements.
- Verify insurance eligibility and policy details.
- Explain estimated expenses, exclusions, and approval status to patients.
Documentation & Claim Processing
- Ensure accurate preparation and submission of claim documents.
- Verify patient files, bills, discharge summaries, investigation reports, and supporting documents before submission.
- Maintain proper records of approvals, denials, and claim settlements.
- Coordinate with billing and medical records departments for claim-related documentation.
Billing & Reconciliation
- Coordinate with billing department for final bill preparation.
- Resolve discrepancies related to insurance deductions and claim settlements.
- Maintain pending claim and outstanding payment records.
- Prepare daily/monthly TPA reports.
Compliance & Quality
- Ensure compliance with hospital policies and insurance guidelines.
- Maintain confidentiality of patient and insurance information.
- Support NABH documentation requirements related to billing and insurance.
Required Qualifications
- Graduate in any discipline (preferred: Healthcare/Hospital Administration, Commerce, or Management).
- Diploma or certification in Hospital Administration/Medical Billing preferred.
Experience
- Minimum 1–3 years of experience in hospital TPA/insurance handling.
- Experience in cashless claim processing preferred.
Required Skills
- Knowledge of medical insurance and cashless processes.
- Good communication and negotiation skills.
- Documentation and record management.
- Computer proficiency (MS Office & Hospital Information System).
- Ability to handle patients professionally.
- Coordination and follow-up skills.
Key Performance Indicators (KPIs)
- Timely submission of pre-authorization requests.
- Claim approval turnaround time.
- Reduction in claim rejection percentage.
- Accuracy of documentation.
- Pending claim follow-up status.
- Patient satisfaction related to insurance handling.
Working Conditions
- Hospital-based role.
- Coordination with patients, TPAs, insurance companies, and internal departments.
- May require extended working hours during high patient load.
Salary
As per hospital policy and experience.
Pay: From ₹20,000.00 per month
Work Location: In person
