Designation: Pre-Authorization, Final Bill & Discharge Summary Validation Executive

Role Purpose

To ensure accurate, compliant, and timely submission of insurance claims by validating pre-authorizations, final bills, discharge summaries, tariffs, approvals, and supporting documents, thereby minimizing claim rejections, revenue leakage, and manual bill edits.

Key Responsibilities
Validate Pre-Authorization (PA) requests before submission to Insurance Companies/TPAs.
Verify patient KYC, insurance card, ID proof, diagnosis, room category, package applicability, LOS, and supporting clinical documents.
Ensure all required investigations, consultation records, and justification letters for package deviations are available.
Review final bills to ensure charges, packages, tariffs, discounts, and approvals are applied as per insurer/TPA agreements.
Validate approval letters and coordinate with IP Managers, Billing Teams, and Insurance/TPAs for necessary corrections.
Calculate and verify non-medical expenses (NMEs), non-payable items, and patient liabilities, and communicate collection requirements to IP teams.
Cross-check diagnosis, procedures performed, billing entries,



and discharge summaries for accuracy and compliance.
Coordinate resolution of insurer/TPA queries and ensure timely claim submissions.
Monitor Preauth submissions through IHX and other designated portals.
Conduct pre-discharge billing audits to identify and rectify discrepancies before claim submission.
Maintain compliance with insurer guidelines, hospital policies, and audit requirements.
Generate exception reports and recommend process improvements to reduce claim deductions and manual bill modifications.

Key Performance Indicators (KPIs)
Reduction in manual bill edits.
Reduction in Preauth rejections and deductions.
First-time-right Preauth submission rate.
Accuracy of tariff, package, and approval validation.
Timely submission of Preauth within SLA.
Reduction in post-discharge billing corrections.

Expected Outcome

Ensure accurate claim processing, improve claim realization, minimize billing errors and deductions, strengthen compliance, and enhance overall insurance revenue management.

📌 Cloudnine Hospital Is Hiring For Tpa Executive Bengaluru (India)
🏢 The Kids Clinic
📍 India