Executive (Claim Operations)

Role & responsibilities

Patient Counseling & Admission Guidance (Front-End Desk)

Greet and counsel patients and their families upon admission regarding health insurance coverage, co-pay clauses, deductions, non-payable items, and overall timelines.

• Set clear expectations with patients regarding pre-authorization procedures, policy sub-limits, and room rent capping to prevent post-discharge disputes.
• Assist patients with initial documentation, verification of active insurance policies, and eligibility checks.
• Cashless Claim Processing & Pre-Authorization
• Prepare and submit complete pre-authorization forms to TPAs and Insurance Companies.
• Coordinate closely with hospital admission desks, nursing staff, and medical records teams to attach required initial clinical notes, diagnostic reports, and estimation letters.
• Follow up continuously with TPA/Insurance desks to secure timely Initial Pre-Auth Approvals and Enhancement Approvals during treatment.

Reimbursement Claim Processing

Guide and assist non-cashless patients with the complete reimbursement documentation workflow.
Collate, verify, and organize original itemized bills, discharge summaries, pharmacy vouchers, implants invoices, diagnostic reports, and payment receipts.Prepare file submissions, dispatch claims to TPA/Insurers, and guide patients on tracking their reimbursement status.TPA Helpdesk & Hospital CoordinationManage day-to-day operations at the hospitals dedicated TPA / Health Insurance Helpdesk.

• Serve as the primary liaison between patients, hospital billing teams, clinical advisors, TPA desk staff, and insurance auditors
• Maintain active coordination with top TPA partners (e.g., Medi Assist, MDIndia, Heritage,
• Paramount, Vidal, etc.).
• Query Resolution & Settlement Tracking (Back-End Operations)
• Monitor and immediately address query letters or deficiency requests raised by TPAs/Insurers to prevent processing delays.
• Facilitate final bill processing, coordinate pre-discharge final authorization approval, and minimize patient waiting time during discharge
• Track claims through the post-discharge lifecycle to ensure final claim settlement, reconciliations, and closure.
• Maintain daily tracking logs of patient admissions, pre-auth status, queries, approvals, rejections, and pending settlements.

Preferred candidate profile

Experience Required: 1-3 Years (Minimum 8-12 months in Hospital TPA Cell / Insurance Desk mandatory)
Must-Have Experience: Direct hands-on experience working in a Hospital TPA Helpdesk, Hospital Insurance Cell, or TPA Company.Domain Expertise: Thorough knowledge of cashless workflows, reimbursement guidelines, ICD codes, pre-authorization forms, medical terminology, and hospital billing documents.

• Soft Skills: Empathetic, calm demeanor with strong patient counseling and crisis negotiation skills.
• Communication: Clear verbal communication skills in English and regional languages (Hindi /
• Kannada / local state language).
• Technical Skills: Basic computer proficiency in Excel, MS Office, and online TPA portal management.