Job Description

Key Responsibilities:

1. Pre-authorization & Claim Management:

Review and validate pre-authorization requests as per medical necessity and insurance policy guidelines. Prepare and submit pre-authorization forms with accurate diagnosis, procedure codes, and estimated costs. Monitor approval status and follow up with TPAs for timely authorization. Scrutinize final bills, discharge summaries, and investigation reports before claim submission.

2. Coordination & Communication:

Coordinate with consultants, nursing staff, and billing teams for complete documentation. Communicate with TPA coordinators and insurance executives for approvals, queries, or discrepancies. Handle patient or attendant queries related to insurance coverage and approvals.

3. Documentation & Compliance:

Ensure all treatment notes, prescriptions, and reports are attached to claims. Maintain accurate and complete records of all TPA-related activities. Verify compliance with IRDA and hospital policies regarding TPA operations.

4. Medical Review:

Evaluate the medical justification of treatment plans and hospital stay. Cross-check diagnosis and procedure coding (ICD/CPT) to avoid rejections. Assist in preparing medical justifications for claim rejections or queries.

5. Reporting:

Prepare daily/weekly/monthly MIS reports on TPA cases, pending approvals, and claim settlements. Track and analyze TPA claim rejection trends to improve documentation accuracy.

Skills & Competencies:

Strong medical assessment and analytical skills. Good communication and coordination abilities. Knowledge of insurance policies and hospital billing systems. Attention to detail and documentation accuracy. Proficiency in MS Office and HIS (Hospital Information System).

Qualifications & Experience:

Education:

MBBS / BAMS / BHMS (MBBS preferred).

Experience:

Minimum 1-3 years in hospital TPA department / insurance claim processing / utilization review.

Knowledge:

Medical coding (ICD, CPT). TPA software systems and hospital billing. Insurance claim workflow and pre-authorization process.
Job Types: Full-time, Permanent

Pay: ?30,597.71 - ?45,512.63 per month

Benefits:

Cell phone reimbursement Leave encashment Paid sick time Paid time off Provident Fund
Education:

Bachelor's (Preferred)
Experience:

TPA: 2 years (Preferred)
Work Location: In person