TPA Executive

Job Title: TPA Billing Executive

Department: Billing / Accounts

Reports To: Billing Manager / TPA Coordinator / Accounts Head

Location: Jabalpur Hospital & Research Centre

Job Summary:

The TPA Billing Executive is responsible for managing and processing cashless and reimbursement claims through various Third-Party Administrators (TPAs) and insurance companies. The role involves preparing, verifying, submitting, and following up on claims to ensure timely and accurate payment, while maintaining compliance with insurance and hospital policies.

Key Responsibilities:

1. Pre-Authorization & Admission Process

* Coordinate with TPAs and insurance companies for pre-authorization approvals.

* Verify the patient’s insurance details and policy coverage at the time of admission.

* Collect necessary documents and ensure completeness before sending for approval.

* Liaise with the treating consultants for required clinical notes and reports.

2. Billing & Claim Preparation

* Prepare patient bills as per TPA/insurance tariff and package guidelines.

* Ensure that all medical services, consumables, and investigations are accurately billed.

* Verify billing details against patient case sheets, charge slips, and doctor orders.

* Upload/submit all required claim documents on TPA portals or via email.

3. Claim Submission & Reconciliation

* Maintain a record of all claims submitted to different TPAs.

* Track pending approvals and coordinate for final authorization before discharge.

* Reconcile claim amounts with TPA payments and resolve discrepancies.

* Coordinate with Accounts Department for payment posting and reconciliation.

4. Follow-up & Settlement

* Follow up with TPAs for pending, rejected, or short-settled claims.

* Address queries or discrepancies raised by TPAs/insurance companies promptly.

* Maintain communication logs and claim status updates.

* Generate and share regular reports on claim status, outstanding, and recovery.

5. Documentation & Compliance

* Maintain proper documentation and filing of all TPA/insurance cases.

* Ensure compliance with hospital policies, TPA agreements, and statutory requirements.

* Protect patient data confidentiality as per hospital and IRDA norms.

Qualifications & Skills:

* Education: Graduate (preferably B.Com / BBA / Hospital Administration).

* A diploma or certification in Medical Billing / TPA Management will be an added advantage.

* Experience: 1–3 years of experience in hospital TPA billing or health insurance claim processing.

Skills:

* Good communication and coordination skills.

* Strong knowledge of TPA procedures and insurance policies.

* Proficiency in MS Office and hospital billing software (HMS).

* Attention to detail and analytical ability.

Key Performance Indicators (KPIs):

* Timely submission and settlement of TPA claims.

* Percentage of claims approved vs. rejected.

* Average turnaround time for claim closure.

* Accuracy in billing and documentation.

Job Types: Full-time, Permanent

Pay: ₹15,000.00 - ₹20,000.00 per month

Benefits:

• Leave encashment
• Paid sick time
• Provident Fund

Work Location: In person