The TPA Executive is responsible for coordinating with insurance companies, TPAs, and government health schemes to facilitate cashless treatment, timely claim submission, reimbursement processing, and compliance with hospital and payer guidelines. The role requires maintaining accurate documentation, ensuring smooth patient service, and minimizing claim rejections.
Key ResponsibilitiesPatient Coordination
- Assist patients and attendants regarding cashless hospitalization and insurance procedures.
- Verify patient identity, insurance eligibility, and policy details.
- Explain required documents and obtain necessary authorizations.
Pre-Authorization
- Prepare and submit pre-authorization requests to TPAs and insurance companies.
- Coordinate with treating consultants and nursing staff for required clinical information.
- Follow up with TPAs/insurers for timely approvals and communicate approval status to the concerned departments.
Claims Processing
- Prepare complete claim files with all supporting documents.
- Ensure accurate coding, billing, and documentation before claim submission.
- Submit final bills and claims within the prescribed timelines.
- Track claim status and follow up for settlement.
Documentation & Compliance
- Maintain complete and accurate records of all TPA and insurance cases.
- Ensure compliance with TPA, insurance company, and government scheme guidelines.
- Maintain confidentiality of patient information at all times.
Coordination
- Coordinate with consultants, billing, medical records, nursing, pharmacy, laboratory, and finance departments for smooth claim processing.
- Respond promptly to queries raised by TPAs, insurers, and government agencies.
- Facilitate audits and inspections by providing required documentation.
Claim Reconciliation
- Monitor approved, pending, and rejected claims.
- Analyze reasons for claim deductions or rejections.
- Prepare and submit clarification letters or additional documents when required.
- Assist in reducing claim rejection rates.
Reporting
- Prepare daily, weekly, and monthly reports on TPA admissions, approvals, claims submitted, settlements, pending cases, and rejections.
- Maintain MIS records and update management regularly.
Pay: ₹10,000.00 - ₹25,000.00 per month
Work Location: In person
