Experience
Minimum 2–5 years of relevant experience in handling Private TPA, and Ayushman Bharat PM-JAY claims in a hospital.
Educational Qualification
- Graduate in any discipline (Healthcare/Hospital Management preferred)
- Computer proficiency certification will be an added advantage.
Key Responsibilities
- Manage complete cashless processing for Private TPA, Insurance Companies, and Ayushman Bharat (PM-JAY) patients.
- Process pre-authorizations, enhancements, discharge approvals, final bill submissions, claim settlements, and query management within prescribed timelines.
- Ensure accurate documentation and compliance with PM-JAY and insurance guidelines.
- Handle the PM-JAY BIS, TMS, HEM, and other relevant portals efficiently.
- Coordinate with treating doctors, nursing staff, billing department, and insurance representatives for timely approvals.
- Verify medical records, treatment protocols, ICD coding (basic knowledge preferred), investigation reports, and discharge summaries before claim submission.
- Follow up on pending authorizations, deficiencies, rejected claims, and payments.
- Maintain daily MIS reports, claim status trackers, pending approvals, and revenue reports.
- Ensure maximum approval rates with minimum claim rejections.
- Coordinate with TPAs, insurance companies, PM-JAY authorities, and government agencies regarding claim-related matters.
- Train and guide internal staff regarding documentation requirements and panel compliance.
- Ensure confidentiality of patient records and comply with hospital policies.
Required Skills
- Proven experience in managing Private TPA and Ayushman Bharat (PM-JAY) operations.
- Thorough knowledge of:
- Pre-Authorization
- Enhancement Requests
- Final Authorization
- Claim Submission
- Query Resolution
- Claim Reconciliation
- Strong technical knowledge of PM-JAY portals and workflows, including package selection, documentation requirements, transaction management, and claim processing.
- Excellent knowledge of medical terminology, clinical documentation, investigations, operative notes, discharge summaries, and treatment protocols.
- Excellent computer skills with advanced proficiency in Microsoft Excel, Word, email, and hospital management software (HIS).
- Ability to prepare reports using Excel (VLOOKUP/XLOOKUP, Pivot Tables, Filters, Basic Formulas, etc.).
- Strong communication, coordination, and negotiation skills.
- Ability to work under pressure and meet strict turnaround times.
Preferred Candidate Profile
- Experience in a NABH/CGHS/PM-JAY empanelled multispecialty hospital will be preferred.
- Knowledge of government healthcare schemes, insurance regulations, and claim compliance.
- Positive attitude, problem-solving ability, and excellent team coordination.
Key Performance Indicators (KPIs)
- Approval rate of cashless cases.
- Reduction in claim rejection percentage.
- Timely submission of pre-authorizations and enhancement requests.
- Faster turnaround time for discharge approvals.
- Recovery of pending claims and settlements.
- Accuracy of documentation and compliance.
- Timely submission of daily and monthly MIS reports.
Pay: ₹15,000.00 - ₹34,875.62 per month
Work Location: In person
