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
- 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.
- 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 rapid approval and authorization letters before planned procedures or emergency admissions.
- 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.
- 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 ju