Head TPA & Claims Process Controller & Audits

Job Specifications

• BAMS/BHMS/MBBS with Post graduation /Healthcare Management

Professional Experience

 years of Experience in a tertiary care hospital or Health Insurance sector

Main Objective of the Role

To Ensure compliance to complete End to End claim processing, disbursement and settlement for All insurance and corporate Patients

Key Responsibilities

Medical Claims Compliance & Processing Oversight

1. Ensure 100% compliance in claims processing through the IHX portal.
2. Monitor the complete end-to-end lifecycle of claims management, including disbursal and settlement.
3. Supervise and review daily, weekly, and monthly claims data: claims raised, under query, pending/disputed, and ageing analysis.
4. Assist local TPA teams in resolving stuck or disputed claims.
5. Ensure claims are settled in line with the agreed MoU with partners and corporates.
6. Monitor and control disallowances and short payments after final approvals.
7. Supervise the claim settlement process within the HMIS system.
8. Liaise, engage, and coordinate with insurance companies and TPA partners.

Claims Audit & Quality Assurance

1. Perform detailed audits of medical claims to ensure accuracy and integrity.
2. Review and verify diagnosis codes, treatment plans, and medical necessity.
3. Identify and rectify errors, discrepancies, or potential fraud in claims submissions.
4. Prepare comprehensive audit reports with findings, recommendations, and corrective actions.
5. Maintain accurate and complete records of audits and corrective measures.

Process Improvement & Compliance

1. Develop and implement efficient claims processing procedures and controls to enhance accuracy and operational efficiency.
2. Monitor and analyze claims trends and processing metrics to identify improvement areas.
3. Ensure adherence to regulatory requirements and best practices.
4. Collaborate with internal teams to refine policies and procedures for claims adjudication.
5. Assist in the development and review of medical policies, clinical guidelines, and criteria for adjudication.