Job Description – TPA Executive (Hospital)
Job Title:
TPA Executive (Third Party Administrator Executive)
Department:
TPA / Insurance Department
Reports To:
TPA Manager / Billing Manager / Hospital Administrator
Job Summary:
The TPA Executive is responsible for coordinating cashless hospitalization services with insurance companies, TPAs, government health schemes, and corporate clients. The role involves obtaining pre-authorizations, maintaining accurate documentation, processing claims, ensuring timely approvals, and providing excellent support to patients throughout the admission and discharge process.
Key Responsibilities:
1. Cashless Authorization
- Process cashless hospitalization requests with TPAs and insurance companies.
- Submit pre-authorization requests with complete medical documentation.
- Follow up with TPAs for timely approvals and query resolution.
- Inform patients and attendants regarding authorization status.
2. Documentation & Claim Processing
- Verify patient insurance cards, ID proofs, and policy details.
- Collect and maintain complete claim documents.
- Prepare and submit final claim documents after patient discharge.
- Ensure documentation complies with TPA and insurance guidelines.
3. Coordination
- Coordinate with doctors, nursing staff, billing, pharmacy, laboratory, and medical records departments.
- Liaise with insurance companies, TPAs, corporate clients, and government health schemes such as ECHS, ESI, CGHS, Ayushman Bharat (PM-JAY), and state health schemes.
- Resolve patient and insurer queries promptly.
4. Billing & Settlement
- Verify hospital bills before claim submission.
- Ensure approved amounts are accurately reflected in patient billing.
- Coordinate with the finance department for claim reconciliation.
- Assist in resolving claim deductions and rejections.
5. Patient Assistance
- Explain cashless admission and discharge procedures.
- Guide patients regarding required documents and approvals.
- Ensure a smooth patient experience during hospitalization.
6. Record Maintenance
- Maintain daily records of admissions, approvals, pending cases, discharges, and claim status.
- Prepare daily, weekly, and monthly MIS reports.
- Keep records updated in the Hospital Information System (HIS).
7. Compliance
- Ensure compliance with hospital policies and insurance guidelines.
- Maintain confidentiality of patient records and insurance information.
- Support internal and external audits related to TPA claims.
Qualifications
- Graduate in any discipline (B.Com, BBA, B.Sc., BA, etc.)
- Preferred: MBA (Hospital Administration), MHA, BHA, or PG Diploma in Hospital Administration.
Experience
- 1–3 years of experience in Hospital TPA, Medical Insurance, or Billing Department.
- Freshers with relevant hospital internship/training may also be considered.
Required Skills
- Knowledge of TPA and insurance claim processing.
- Experience with ECHS, ESI, CGHS, Ayushman Bharat (PM-JAY), and private insurance claims.
- Familiarity with Hospital Information Systems (HIS) and Microsoft Office.
- Good communication and interpersonal skills.
- Strong documentation and record-keeping abilities.
- Ability to work under pressure and meet deadlines.
- Problem-solving and coordination skills.
- Attention to detail and accuracy.
Key Performance Indicators (KPIs)
- Timely submission of pre-authorizations.
- Cashless approval turnaround time.
- Claim acceptance rate.
- Reduction in claim rejections and deductions.
- Timely submission of final bills and claim documents.
- Patient satisfaction score.
- Accuracy of documentation.
- Compliance with TAT (Turnaround Time).
Working Conditions
- Hospital environment.
- Rotational shifts, including weekends and public holidays if required.
- Frequent interaction with patients, insurance representatives, doctors, and hospital staff.
This job description is suitable for multispecialty hospitals handling private insurance, ECHS, ESI, CGHS, Ayushman Bharat (PM-JAY), and corporate cashless patients.
Pay: ₹15,075.81 - ₹24,509.61 per month
Work Location: In person
