TPA Manager – ESI / WBHS / CGHS / ECHS / Ayushman Bharat
Job Description:
We are looking for an experienced TPA Manager responsible for end-to-end management of TPA, government health scheme, cashless authorization, billing, claims processing, documentation, and reimbursement activities for ESI, WBHS, CGHS, ECHS, Ayushman Bharat and other empanelled schemes.
Key Responsibilities:
- Manage the complete TPA and government scheme operations from patient registration to final claim settlement.
- Handle ESI, WBHS, CGHS, ECHS and Ayushman Bharat cases and ensure smooth cashless services.
- Coordinate with TPAs, government authorities, insurance companies, scheme offices and hospital departments.
- Ensure timely pre-authorisation, approval, enhancement, discharge approval and claim submission.
- Monitor claim documentation, coding, billing, deductions, queries, rejections and resubmissions.
- Ensure accurate and timely submission of claims and reimbursement documents as per respective scheme guidelines.
- Coordinate with doctors, billing, medical records, nursing, pharmacy, diagnostics and other departments for complete documentation.
- Monitor outstanding claims, pending approvals, rejected claims and deductions and take corrective action.
- Handle TPA/insurance queries, audits, inspections and claim-related escalations.
- Maintain updated records, registers, MIS and daily/monthly reports for all schemes.
- Monitor claim turnaround time, approval ratio, rejection ratio, deductions and revenue realization.
- Ensure compliance with applicable scheme guidelines, hospital policies, contractual requirements and statutory regulations.
- Train and supervise the TPA/Insurance desk team and ensure proper work allocation and performance.
- Identify process gaps and implement measures to improve claim efficiency, revenue realization and patient satisfaction.
- Coordinate regularly with Head Office/Management regarding claim status, revenue, outstanding, disputes and operational issues.
Key Skills:
TPA Management, ESI, WBHS, CGHS, ECHS, Ayushman Bharat, Cashless Authorization, Pre-Authorization, Claims Processing, Medical Billing, Insurance Coordination, Government Health Schemes, Reimbursement, Claim Audit, Query Management, Revenue Cycle Management, MIS Reporting, Team Management, Hospital Operations.
Qualification:
Graduate in any discipline. MBA/MHA/PGDM in Hospital Management, Healthcare Management or related field will be preferred.
Experience:
4–7 years of relevant experience in TPA/Insurance/Government Health Scheme operations in a hospital or healthcare organization, with strong hands-on experience in ESI, WBHS, CGHS, ECHS and Ayushman Bharat.
Key Performance Areas:
Claim Submission | Cashless Approval | Claim Settlement | Revenue Realization | Reduction in Rejections & Deductions | Outstanding Management | TPA Coordination | Government Scheme Compliance | Team Productivity | Patient Service
Pay: ₹15,000.00 - ₹30,000.00 per month
Work Location: In person
