TPA MEDICAL OFFICER

Key Responsibilities:

1. Pre-authorization & Claim Management:

• Review and validate pre-authorization requests as per medical necessity and insurance policy guidelines.
• Prepare and submit pre-authorization forms with accurate diagnosis, procedure codes, and estimated costs.
• Monitor approval status and follow up with TPAs for timely authorization.
• Scrutinize final bills, discharge summaries, and investigation reports before claim submission.

2. Coordination & Communication:

• Coordinate with consultants, nursing staff, and billing teams for complete documentation.
• Communicate with TPA coordinators and insurance executives for approvals, queries, or discrepancies.
• Handle patient or attendant queries related to insurance coverage and approvals.

3. Documentation & Compliance:

• Ensure all treatment notes, prescriptions, and reports are attached to claims.
• Maintain accurate and complete records of all TPA-related activities.
• Verify compliance with IRDA and hospital policies regarding TPA operations.

4. Medical Review:

• Evaluate the medical justification of treatment plans and hospital stay.
• Cross-check diagnosis and procedure coding (ICD/CPT) to avoid rejections.
• Assist in preparing medical justifications for claim rejections or queries.

5. Reporting:

• Prepare daily/weekly/monthly MIS reports on TPA cases, pending approvals, and claim settlements.
• Track and analyze TPA claim rejection trends to improve documentation accuracy.

Skills & Competencies:

• Strong medical assessment and analytical skills.
• Good communication and coordination abilities.
• Knowledge of insurance policies and hospital billing systems.
• Attention to detail and documentation accuracy.
• Proficiency in MS Office and HIS (Hospital Information System).

Qualifications & Experience:

• Education: MBBS / BAMS / BHMS (MBBS preferred).
• Experience: Minimum 1–3 years in hospital TPA department / insurance claim processing / utilization review.
• Knowledge:
• Medical coding (ICD, CPT).
• TPA software systems and hospital billing.
• Insurance claim workflow and pre-authorization process.

Job Types: Full-time, Permanent

Pay: ₹30,597.71 - ₹45,512.63 per month

Benefits:

• Cell phone reimbursement
• Leave encashment
• Paid sick time
• Paid time off
• Provident Fund

Education:

• Bachelor's (Preferred)

Experience:

• TPA: 2 years (Preferred)

Work Location: In person