Job Description

The TPA Head will be responsible for overseeing all Third-Party Administrator (TPA) and insurance-related activities in the hospital. The role involves managing cashless processes, billing approvals, claims settlement, coordination with insurance companies, and ensuring compliance with regulatory requirements.

Key Responsibilities:

1. Operations Management

Supervise and monitor the entire TPA and insurance operations of the hospital. Ensure timely and accurate processing of pre-authorizations, approvals, and discharge summaries. Maintain coordination between patients, doctors, billing, and TPA executives for smooth cashless operations. Oversee the claim submission process and follow up on pending or rejected claims. Ensure accuracy of documentation and adherence to insurance/TPA guidelines.

2. Financial & Claims Management

Review and approve all insurance and TPA-related bills before submission. Monitor claim settlements and ensure timely payments from insurance companies. Track receivables, reconcile accounts, and minimize claim rejections. Prepare MIS reports on TPA collections, outstanding claims, and rejections.

3. Coordination & Liaison

Build and maintain strong relationships with TPA representatives and insurance companies. Liaise with consultants and clinical teams for proper documentation and justification of medical procedures. Act as a point of escalation for complex or disputed cases.

4. Team Management

Lead, train, and monitor the TPA team to ensure efficiency and service quality. Allocate responsibilities and monitor daily operations to maintain turnaround times.

5. Compliance & Quality

Ensure compliance with hospital policies and IRDA guidelines. Periodically audit insurance files and claim documentation. Implement continuous process improvement in TPA operations.

Key Skills & Competencies:

Strong knowledge of hospital billing, insurance procedures, and TPA processes Excellent communication and negotiation skills Analytical and problem-solving ability Team leadership and multitasking skills Proficiency in hospital billing software and MS Office

Qualification:

Graduate in any discipline (preferably BAMS / BHMS / BHA)

Experience:

Minimum 5-6 years in TPA/Insurance coordination
Job Type: Full-time

Work Location: In person