TPA Executive

Job Description: TPA / Mediclaim Executive

Position Title: TPA Executive / Insurance Desk Executive

Department: TPA & Health Insurance / Billing

Reports To: TPA Manager / Billing In-Charge / Medical Superintendent

Job Purpose

The TPA Executive acts as the primary bridge between the hospital, insurance companies, Third Party Administrators (TPAs), and patients. The role involves facilitating cashless hospitalizations, managing pre-authorizations, ensuring accurate claims documentation, and coordinating timely claim settlements within strict Turnaround Times (TAT).

Key Responsibilities

1. Patient Assistance & Admission Desk

• Assist incoming patients at the TPA desk with policy verification, eligibility checks, and cashless claim registration.

• Guide patients and their families on policy coverage limits, co-payment terms, non-payable items, and cashless process flows.

• Collect mandatory KYC documents, insurance cards, and medical histories at the time of admission.

2. Pre-Authorization Management

• Coordinate with attending doctors and nursing staff to obtain clinical details, diagnostic reports, and pre-auth forms.

• Fill out and upload pre-authorization requests to TPA/insurance company portals promptly.

• Follow up continuously with insurance medical officers to ensure fast approval and authorization letters before planned procedures or emergency admissions.

3. Claim Processing & Discharge Management

• Prepare final claim packages during discharge, including itemized medical bills, pharmacy breakups, diagnostic reports, and signed discharge summaries.

• Ensure strict adherence to insurance package rates and hospital-approved tariffs.

• Submit final billing dossiers to TPA desks/portals within the stipulated discharge TAT to avoid delay in patient relief.

4. Query Resolution & Claims Follow-up

• Monitor and track all pending queries, initial rejection notes, or additional documentation requests from insurers.

• Work with treating physicians to provide clinical justifications or clarifications required by insurance audit teams.

• Track outstanding balances, claim short-payments, and pending settlements with various TPA agencies.

5. Documentation & Compliance

• Maintain accurate electronic logs and registers of all pre-auth requests, approvals, rejections, and pending receivables.

• Coordinate with the hospital accounts/finance department for reconciliation of settled insurance payments.

• Ensure strict compliance with IRDAI guidelines, patient privacy standards, and insurer MOUs.

Required Skills & Qualifications

• Education: Bachelor’s degree in Healthcare Management (BHA), Commerce/Arts/Science, or Allied Health Sciences (BAMS/BHMS/BSc Nursing or Diploma in Hospital Administration).

• Experience: 1–3 years of hands-on experience handling TPA/insurance claims desk operations in a hospital or healthcare setup.

• Key Technical Knowledge:

  • Proficiency with major TPA web portals (Medvantage, Medi Assist, Vidal, Paramount, Heritage, Star Health, ICICI Lombard, etc.).

  • Familiarity with medical terminology, ICD coding, treatment packages, and procedure protocols.

  • Working knowledge of Hospital Information Systems (HIS) and Microsoft Excel.