Corporate Billing Executive

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Key responsibilities

1. Pre-authorization and eligibility verification

• Insurance and TPA patients:

   Verify patient insurance coverage, eligibility, and benefits before or at the time of processing. Contact insurance companies/SPOC’s to obtain precertification or prior authorization for procedures and services as required. Communicate with patients to inform them of their coverage details, financial responsibilities (e.g., co-pays and deductibles), and any payment plans.

• Government scheme patients:

   Confirm eligibility for schemes like the Central Government Health Scheme (CGHS), Ayushman Bharat (PM-JAY), or state-specific schemes (e.g., CMCHIS) and obtain necessary approvals. Aware of the respective billing process and codes as per the specific schemes.

• Corporate patients:

   Verify patient eligibility based on the hospital's corporate tie-up agreements. 

2. Documentation and submission

• Accurately enter and process large volumes of patient admission data, billing details, and discharge summaries from various units into respective units customer portals or mails.
• Conduct thorough checks of admission and billing documents, including insurance details, patient demographics, and medical records, to identify and correct discrepancies before claims submission
• Compile and review all required medical and billing documents for each claim type.
• Ensure accurate and compliant medical coding (e.g., ICD-10, CPT) for all diagnoses and procedures, following the specific guidelines of the payer.
• Submit claims electronically or manually to the respective insurance company, TPA, or government and corporate portals within defined timelines. 

3. Billing and processing

• Prepare/Verify/Generate accurate bills according to the specific tariff and billing rules of the insurance plan, government scheme, or corporate agreement.
• Verify payments, rejections, and denials received from all payers into the hospital's billing system.
• Reconcile accounts to ensure all payments are correctly received without any deduction. 

4. Denial management and appeals

• Investigate the reasons for denied or underpaid claims from all sources, including denials based on policy exclusions or package rates.
• File timely and well-documented appeals to insurance companies, TPAs, and government scheme offices.
• Follow up rigorously on all approvals and outstanding claims to ensure a high rate of approval/collection.
• Identify denial trends to suggest process improvements and minimize future queries and rejections.

5. Communication and collaboration

• Act as the primary point of contact for patients (Backend support), TPAs, corporate HR, and government scheme representatives for all billing and claims-related inquiries.
• Coordinate with internal departments, such as clinical teams, patient admissions and billing to ensure accurate and timely documentation for claims
• Provide support and guidance to colleagues on best practices for claims processing and patient billing. 

6. Compliance and reporting

• Prepare and submit daily, weekly, and monthly reports on key metrics such as admission volumes, billing accuracy, and process turnaround times. Generate regular reports on approval/claims status, payment trends, and outstanding receivables for management.
• Analyze backend data to identify trends, pinpoint common errors, and suggest improvements to enhance efficiency across all units
• Maintain updated knowledge of regulations, policy changes, and scheme guidelines for all types of payers.
• Generate and maintain accurate records of processed claims and provide reports on claims status and performance metrics to management.
• Regular meetings with operations and billing teams, focus on improving the credit bill process, analyzing the reasons for disallowances, and ensuring associated deliverables are met effectively.

Qualifications and requirements

Experience:

• Proven experience in large volume medical claims processing, insurance verification, and hospital billing with specific experience handling claims from multiple payer types (e.g., TPAs, government schemes, corporate, etc).
• Knowledge of medical terminology, medical billing cycles, and health insurance regulations.
• Aware of Package Medical Billing and Coding (e.g., CGHS, ECHS, etc) is often preferred. 

Skills:

• Process expertise: Deep understanding of hospital admissions, billing, and revenue cycle management.

• Analytical skills:

   Ability to analyse complex claims data, identify discrepancies, and solve problems effectively. Ability to process large volumes of data and identify trends.

• Attention to detail:

   Meticulous and accurate in reviewing claims and entering data.

• Communication skills:

   Excellent written and verbal communication for interacting with patients, insurance companies, and staff.

• Technical proficiency:

   Proficient in medical billing software, electronic health records (EHR), and Microsoft Office Suite.

• Organizational skills:

   Strong ability to manage multiple tasks, prioritize workload, and meet deadlines.

• Customer service:

   A patient-centric mindset with empathy for individuals facing complex healthcare situations. 

• Flexibility:

   Must be able to adapt to changing situations and travel to different hospital units on short notice.