TPA Executive – Govt. Panel (CGHS, ECHS, DGHS, PMJAY)

Department: Insurance / TPA Desk / Billing
Reports to: TPA Manager / Insurance Head / Billing Manager
Qualification: Graduate in any stream (Commerce/Life Sciences preferred); certification in Hospital Administration or Health Insurance is an added advantage
Experience: 1–3 years in TPA/Govt. scheme billing in a hospital setup

Key Responsibilities:
- Handle end-to-end patient empanelment verification and eligibility checks for CGHS, ECHS, DGHS, and PMJAY (Ayushman Bharat) beneficiaries at admission
- Process pre-authorization requests for cashless treatment under respective govt. schemes and follow up for timely approvals
- Prepare and submit accurate claim files as per scheme-specific package rates, documentation checklists, and portal requirements (CGHS portal, ECHS portal, PMJAY/NHA portal, DGHS empanelment guidelines)
- Ensure correct application of applicable package codes/rates and coordinate with billing team to avoid over/under-billing
- Maintain updated knowledge of scheme circulars, rate revisions,



empanelment renewals, and policy changes issued by CGHS/ECHS/DGHS/NHA
- Coordinate with treating doctors and medical records department to obtain complete clinical documentation (discharge summary, investigation reports, referral/consultation slips) required for claims
- Track claim status post-submission, respond to queries/deficiencies raised by scheme authorities, and resubmit corrected claims within stipulated timelines
- Follow up for reimbursement/payment realization; escalate delayed or rejected claims and maintain claim ageing/MIS reports
- Liaise with CGHS Wellness Centres, ECHS Polyclinics, and empanelment cells for approvals, referrals, and grievance resolution
- Assist patients/attendants in understanding scheme entitlements, referral validity, and required documentation
- Maintain empanelment records, renewal timelines, and ensure hospital compliance with scheme terms & conditions to avoid de-e

📌 TPA Executive (Rajouri Garden)
🏢 KUKREJA HOSPITAL & HEART CENTRE
📍 Rajouri Garden