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-empanelment
- Coordinate hospital audits/inspections conducted by CGHS/ECHS/NHA/DGHS teams
- Maintain MIS on claims submitted, approved, rejected, and pending amounts for management reporting
- Ensure strict confidentiality of patient and financial data as per hospital policy

Skills Required:

- Sound knowledge of CGHS/ECHS/DGHS package rates and PMJAY (Ayushman Bharat) guidelines
- Proficiency in respective govt. portals (CGHS online, ECHS, NHA/PMJAY TMS, e-Upchaar etc.)
- Strong documentation, follow-up, and coordination skills
- MS Excel and hospital HIS/billing software proficiency
- Good communication skills (English/Hindi) for liaising with scheme officials, doctors, and patients
- Ability to handle claim rejections/deficiencies with problem-solving approach

Key Performance Indicators (KPIs):

- Turnaround time for pre-authorization and claim submission
- Claim rejection/deficiency rate
- Claim realization percentage and ageing of outstanding dues
- Empanelment compliance and audit readiness

Pay: ₹10,029.11 - ₹25,537.45 per month

Advantages

- Cell phone reimbursement
- Commuter assistance
- Flexible schedule
- Internet reimbursement
- Leave encashment
- Paid sick time
- Paid time off
- Provident Fund

Work Location: In person

📌 TPA Executive (Rajouri Garden)
🏢 Kukreja Hospital u0026 Heart Centre
📍 Rajouri Garden