Job Description

Insurance Eligibility Check Understanding of Health Insurance terminologies Such as Sum insured, Balance Sum

insured , Room eligibility, Capping/Sublimit , Coverage , NME

Explore corporate based insurance eligibility Pre-Auth Document Validation and Adjudication: Validate and adjudicate pre-authorization documents. Ensure all necessary documents are shared with the hospital and that pre-authorization

is raised and followed up on effectively.

Approval and Communication: Update the internal tool once approval is received from the hospital. Provide financial counseling to patients as needed, in coordination with the CB

(Customer/Billing).

Hospital Alignment: Ensure proper alignment with hospitals to avoid miscommunication. Confirm that the hospital conducts financial counseling, obtains patient consent, and

shares the signed copy with the MB Financial Operations team.

Query Resolution: Ensure timely resolution of queries for all cases. Pre-Auth and Claim Rejections: Share a list of all pre-auth rejection cases with the IS TLs for cash and EMI counseling. For claim rejection cases, persuade patients to opt for cash (first preference) or EMI

options, and explain these options to both the CB and the patient, if required.

Discharge Process Carefully review discharge documents before sharing them with the TPA to ensure room

eligibility, tariff accuracy, and genuine billing.

Address TPA queries promptly and provide clear justifications to minimize repeated or

multiple queries.

Ensure that hospitals collect out-of-pocket (OOP) payments as per the discharge

approval to avoid excess payments.

Monitoring and Communication: Monitor WhatsApp groups and emails for any concerns raised by hospitals and the

Inside Sales Team.

Assist Inside Sales in document collection and sharing, ensuring cases are properly

raised in Lead Square.

Basic Requirements:

Medical Background: Understanding of medical terminology and procedures.

Experience in Hospital Billing and Insurance: Familiarity with hospital billing processes

and insurance claims.

TPA Insurance SPOC: Experience as a single point of contact for TPA insurance

processes.

Preferred Qualifications:

Strong communication and interpersonal skills. Ability to work collaboratively with hospitals, patients, and internal teams. Proficiency in using financial and healthcare management tools. Attention to detail and problem-solving skills. This JD outlines the responsibilities and qualifications for a Senior Associate role

focused on -pre-authorization and cashless processes in financial operations. Adjust the

details as needed to fit your organization's specific requirements.