TPA Executive

Job Description

Key Responsibility Areas (KRA) Hospital TPA Desk Executive Designation: MDIndia TPA Desk Executive Location: Assigned Hospital Reporting To: MDIndia Provider Management Head Office 1. Claims Processing & Coordination Facilitate the Green Channel process to ensure zero waiting time for patient admissions and discharges. Prioritize and assist with the admission of VIP clients and corporate patients for a seamless experience. Support the end-to-end processing of cashless and reimbursement claims efficiently. Coordinate with the hospital billing and finance team for smooth claim approvals and disbursements. Liaise with the Head Office to resolve claim-related issues promptly. 2. Patient Assistance & Query Resolution Serve as the single point of contact for patients regarding their insurance claims for the specific hospital. Educate patients and their families about the claim process, required documentation, and eligibility criteria . Address and resolve patient grievances related to claims processing, escalating unresolved issues when necessary. 3. Hospital Liaison & Relationship Management Maintain strong professional relationships with hospital administrators, doctors, and billing teams. Collaborate with hospital staff to ensure seamless admission and discharge procedures for insured patients. Conduct regular meetings with hospital management to streamline TPA processes and improve service efficiency. 4. Reporting & Communication Prepare and submit daily/weekly reports on claim status, patient queries, and pending cases to the central office. Communicate any hospital-specific challenges, delays, or process gaps to management for quick resolution. Stay updated with latest TPA policies, regulatory guidelines, and hospital agreements . 5. Fraud Prevention & Risk Mitigation Adhere to strict protocols to prevent fraudulent activities in claims processing. Ensure seamless coordination with the MDIndia Head Office team to mitigate risks. 6. Customer Service & Satisfaction Provide prompt support and clear guidance to insured patients for a positive customer experience. Conduct feedback sessions to identify patient concerns and suggest process improvements. Enhance customer satisfaction by reducing waiting time for admissions, claims, and grievance resolution. 7. Wellness & Value-Added Services Coordination Coordinate with hospital teams for VIP health checkups, doctor consultations, and second opinion arrangements . Organize OPD service arrangements in the hospital for insured patients. Inform the Head Office team about new hospital initiatives and developments. Keep the Head Office updated on competitor processes and industry trends for strategic planning. Key Performance Indicators (KPIs) 1. Turnaround Time (TAT) – Speed of priority admissions and discharges. 2. Claim Accuracy Rate – Number of claims processed without discrepancies. 3. Patient Satisfaction Score – Feedback from patients and hospital staff. 4. Compliance Adherence – Ensuring 100% compliance with regulatory requirements. 5. Hospital Coordination Efficiency – Effectiveness of hospital staff and management liaison. 6. Query Resolution Time – Average time taken to resolve patient/hospital queries. 7. Wellness Service Delivery – Efficiency in coordinating VIP checkups, OPD services, and second opinions.