Tpa jobs

Job Title: Manager – TPA & Cashless Operations

Department: Billing
Reporting To: Hospital Director

1. Job Objective

To serve as the primary point of contact for all insurance-related matters, ensuring a seamless cashless treatment experience for patients while maintaining 100% accuracy in claim processing and timely reimbursement for the hospital.

2. Key Responsibilities

• TPA & Private Insurance: Manage the entire lifecycle of private insurance claims, from checking policy validity and initiating Pre-Authorization to resolving queries and final discharge processing.
• PMJAY (Ayushman Bharat) Management: Act as the lead coordinator for the PMJAY scheme. This includes patient identification, Package Blocking, uploading clinical evidence on the TMS portal, and ensuring successful claim submission.
• Liaison & Empanelment: Maintain professional relationships with TPA executives and Insurance companies. Assist the management in the renewal of empanelment contracts.
• Query Handling: Coordinate with doctors and nursing staff to provide clinical justifications and additional documents required by insurance companies to prevent claim rejections.
• Claim Settlement & Recovery: Monitor the accounts receivable for the cashless department. Track pending payments and ensure that all settled claims are credited to the hospital bank account within the stipulated TAT (Turnaround Time).
• Patient Counseling: Explain the cashless process, inclusions, and exclusions to patients and their families to ensure transparency and avoid disputes during discharge.
• Audit & Compliance: Ensure all files are documented as per NABH and Insurance regulatory standards.

3. Required Skills & Qualifications

• Education: Graduate in any stream. A Master’s in Hospital Administration (MHA/MBA) or a Bachelor’s in a medical field (BAMS/BHMS/B.Sc Nursing) is highly preferred.
• Experience: 3–7 years of experience in a hospital TPA department, specifically handling both private insurance and government schemes like PMJAY.
• Technical Proficiency: Must be an expert in the PMJAY Portal (TMS) and various TPA web portals. Proficiency in MS Excel for reporting is essential.
• Negotiation Skills: Ability to coordinate effectively with insurance doctors and TPA auditors to justify medical necessity.

4. Performance Indicators (KPIs)

• Percentage of claims approved versus rejected.
• Average time taken to initiate Pre-auth (TAT).
• Reduction in "Discharge to File Submission" time.
• Resolution of pending payments older than 45 days.

Pay: ₹30,000.00 - ₹50,000.00 per month

Work Location: In person