Tpa Medical Officer

Paras Hospital Gurgaon is hiring TPA Doctor.

Role Overview

The TPA Medical Officer is responsible for reviewing and validating patient treatment documents, coordinating with Third Party Administrators (TPAs) and insurance companies, ensuring timely approvals, managing queries related to cashless and reimbursement cases, and supporting the hospital in achieving accurate and timely claim settlements.

Key Responsibilities

1. TPA Coordination & Approvals

• Review patient treatment files, doctor notes, investigation reports, and clinical documentation for accuracy and completeness.
  
• Prepare and submit Pre-Authorization (Pre-Auth) requests to TPAs/insurance companies.
  
• Ensure timely follow-up for approvals, queries, or enhancements.
  
• Coordinate with treating consultants for justifications and medical clarifications required by TPA.
  
• Handle conversions from cashless to self-pay when required.
  

2. Documentation & Claim Management

• Verify clinical documents before final submission for cashless or reimbursement claims.
  
• Ensure documentation complies with TPA/insurance guidelines.
  
• Maintain a tracker for pre-auth approvals, denial cases, and pending queries.
  
• Support TPA and billing teams in accurate claim submission.
  
• Handle queries related to discharge approvals and final authorization.
  

3. Patient Interaction & Support

• Educate patients/attendants regarding TPA processes, approvals, and documentation requirements.
  
• Update patients on approval status and coordinate discharge as per final authorization.
  
• Address patient concerns related to TPA policies and coverage.
  

4. Coordination with Internal Departments

• Collaborate with consultants, nursing, billing, and admission teams for seamless TPA operations.
  
• Ensure accurate entry of diagnosis, procedures, and documentation as per ICD coding (preferable knowledge).
  
• Work closely with billing team for final bill validation as per TPA tariffs.
  

5. Compliance & Quality

• Ensure all TPA processes follow hospital policies and insurance standards.
  
• Maintain confidentiality of patient data and adhere to NABH/NABL guidelines.
  
• Support audits related to TPA claims and documentation.
  

Qualifications & Experience

• MBBS/BAMS/BHMS or relevant medical qualification.
  
• Experience: 14 years in TPA/Insurance/Claims/Medical Administration in a hospital setting.
  
• Strong understanding of clinical documentation and medical terminology.
  
• Knowledge of TPA/insurance guidelines and cashless claim processes preferred.
  

Skills Required

• Excellent communication and coordination skills.
  
• Strong follow-up and documentation abilities.
  
• Good understanding of hospital operations and medical records.
  
• Ability to handle high-pressure situations and manage multiple cases simultaneously.
  
• Proficiency in MS Office and hospital information systems (HIS).

Regards

Shobhit Nayal

9810802312