Job Description

A TPA (Third-Party Administrator) & Billing Manager coordinates healthcare billing for insured patients, acting as a bridge between hospitals/providers, TPAs, and insurers, focusing on smooth cashless processes, accurate claim submissions, < pre-authorizations, managing rejections, and ensuring compliance, while the broader Billing Manager oversees the entire revenue cycle, team, reporting, and process optimization for all billing, ensuring financial accuracy and efficiency. TPA & Billing Responsibilities (Hospital/Provider Focus)

Patient & Claims Management

: Verify TPA cards, ID proofs, assist with forms, manage pre-authorizations, and handle cashless requests.

Coordination

: Liaise with hospital departments, TPAs, and insurance companies for approvals, follow-ups, and discrepancies.

Documentation

: Ensure correct patient data, policy details, and claim documents are submitted.

Issue Resolution

: Address claim rejections, discrepancies, and follow up on unpaid claims.

Compliance

: Adhere to TPA/insurer guidelines and regulatory norms.
TPA Responsibilities in EmpanelmentThe TPA's role in the empanelment process and subsequent service management includes:

Hospital Network Management:

Identifying, evaluating, monitoring, and empanelling hospitals to build a wide network for cashless treatment options for policyholders.

Negotiating Rates:

Negotiating and agreeing upon treatment rates and service quality standards with hospitals (often using standardized "package rates").

Documentation and Verification:

Defining and managing the documentation requirements for both hospital empanelment and individual claim processing.

Issuing Guidelines:

Establishing the procedures and rules that network hospitals must follow, in compliance with the Insurance Regulatory and Development Authority of India (IRDAI) regulations.

System Integration:

Providing the necessary technological infrastructure (e.g., portals, APIs) for hospitals to submit pre-authorization requests and claims efficiently.
Hospital Responsibilities in EmpanelmentAn empaneled hospital (or a TPA desk within the hospital) has the following responsibilities:

Compliance with Standards:

Meeting and maintaining the infrastructure, quality, and service standards (e.g., NABH accreditation, qualified medical staff) required by the TPA and insurer.

Adhering to Agreed Rates:

Billing the TPA according to the pre-negotiated tariff rates and applying agreed-upon discounts.

Processing Cashless Requests:

Facilitating cashless treatment for insured patients by submitting pre-authorization requests to the TPA promptly (within 24 hours for emergencies).

Documentation and Billing:

Ensuring accurate and complete documentation, including medical records, final bills, and discharge summaries, and submitting them to the TPA on time for processing and payment follow-up.

Patient Guidance:

Assisting policyholders with the claim process, explaining policy exclusions (e.g., non-medical expenses), and clarifying any potential out-of-pocket expenses.
A hospital Billing Manager oversees the entire revenue cycle, managing staff, medical coding, claim submission, accounts receivable, and collections to maximize cash flow while ensuring accuracy and compliance with HIPAA/regulations. Key duties include leading the billing team, developing policies, resolving complex issues with patients/insurers, analyzing data for improvements, and reporting performance to management. Core Responsibilities

Operations Oversight:

Directs daily activities like charge entry, payment posting, claims submission, denial management, and follow-up.

Team Leadership:

Hires, trains, supervises, and supports billing staff, fostering efficiency and accuracy.

Financial Management:

Monitors accounts receivable, manages collections, optimizes revenue, and handles budgeting.

Compliance & Accuracy:

Ensures adherence to healthcare regulations (like HIPAA) and state/federal mandates, and verifies correct medical coding.

Process Improvement:

Analyzes billing data to identify trends, resolves discrepancies, and implements strategies to improve efficiency.

Stakeholder Communication:

Acts as a liaison with patients, insurance companies, and other hospital departments (like Finance/Customer Service) to resolve issues.

Reporting:

Prepares and presents detailed billing activity reports and financial metrics to senior management
Job Types: Full-time, Permanent

Pay: Up to ₹20,000.00 per month

Benefits:

Provident Fund
Work Location: In person