Job Profile / for an Insurance Claim Handler suitable for use at Shri Sai Hospital, Madurai.

SHRI SAI HOSPITAL, MADURAI

JOB PROFILE – INSURANCE CLAIM HANDLER

1. Job Title

Insurance Claim Handler / Insurance Coordinator
1. Department

Insurance & Billing Department
1. Reporting To

Hospital Administrator / Insurance Department In-charge
1. Job Purpose

To efficiently coordinate and manage the complete insurance and Third-Party Administrator (TPA) claim process from patient admission through discharge and final claim settlement, ensuring timely documentation, accurate billing, compliance with insurance requirements, and minimal claim deductions or rejections.
1. Key Duties & Responsibilities

A. Insurance Desk & Patient Coordination
- Verify the patient’s insurance policy, TPA details, eligibility, coverage and validity at the time of admission.
- Collect and verify all required insurance documents from the patient/attender.
- Explain the insurance process, required documents, approvals and limitations to patients and relatives.
- Coordinate with the admission, billing, medical records, nursing and clinical teams.
- Maintain proper communication with patients/attenders regarding the status of insurance approval and claim processing.

B. Pre-Authorization / Cashless Approval
- Initiate pre-authorization requests promptly after admission.
- Ensure accurate submission of diagnosis, clinical findings, proposed treatment, investigations and estimated expenses.
- Coordinate with treating consultants to obtain necessary clinical information and treatment plans.
- Follow up with insurance companies/TPAs for pre-authorization approval.
- Communicate approval status and approved amount to the concerned departments and patient/attender.
- Obtain enhancement approvals whenever the treatment cost exceeds the initially approved amount.
- Ensure all enhancement requests are supported by appropriate clinical documentation.

C. During Hospitalization
- Monitor insurance cases on a daily basis.
- Track approved amount versus actual hospital expenditure.
- Identify cases where the expected bill may exceed the approved insurance amount.
- Coordinate with doctors and departments for timely submission of additional medical information requested by the insurer/TPA.
- Ensure that investigation reports, procedure notes, operative notes, progress notes and other relevant records are available.
- Maintain a list of pending approvals, queries and documentation requirements.

D. Discharge & Final Authorization
- Coordinate with the treating consultant regarding discharge advice.
- Ensure the final diagnosis, procedures and treatment details are correctly documented.
- Coordinate with the billing department to prepare the final bill in accordance with insurance/TPA requirements.
- Prepare and submit the final claim documents promptly.
- Obtain final discharge authorization from the insurance company/TPA.
- Coordinate with the medical records department for preparation and submission of the discharge summary and supporting documents.




- Ensure that all required documents are complete before claim submission.

E. Claim Submission & Settlement
- Prepare and submit complete insurance claim files within the prescribed timelines.
- Verify claim forms, bills, receipts, investigation reports, discharge summaries, operative notes, consent forms and other supporting documents.
- Track submitted claims until final settlement.
- Follow up regularly on pending claims, queries and payment status.
- Coordinate with insurance companies/TPAs regarding claim clarifications.
- Maintain a systematic record of approved, pending, queried, rejected and settled claims.

F. Handling Queries, Deductions & Rejections
- Review insurance/TPA queries and respond within the required timeframe.
- Coordinate with consultants and hospital departments to obtain clarification or missing documentation.
- Analyze deductions made by insurance companies/TPAs.
- Identify avoidable deductions arising from documentation, billing or coding errors.
- Escalate disputed or inappropriate deductions to the Insurance In-charge/Hospital Administrator.
- Follow up on rejected claims and initiate resubmission or appeal wherever appropriate.
- Maintain a record of recurring reasons for deductions and rejections.

G. Documentation & Record Maintenance
- Maintain accurate physical and electronic insurance claim records.
- Ensure confidentiality and secure handling of patient and insurance information.
- Maintain daily records of:
- Current insurance admissions
- Pre-authorizations
- Enhancement requests
- Discharges
- Pending claims
- Insurance queries
- Rejected claims
- Settled claims
- Outstanding amounts
- Ensure proper filing and retrieval of insurance-related documents.

H. Coordination with Hospital Departments

Maintain close coordination with

- Consultants and Duty Medical Officers
- Nursing Department
- Billing & Accounts
- Medical Records Department
- Pharmacy
- Laboratory
- Radiology
- OT/Procedure areas
- Admission & Front Office
- Hospital Administration

Ensure that documentation and information required for insurance processing are obtained without unnecessary delay.
1. Daily Responsibilities

- Review all active insurance cases.
- Check pending pre-authorizations and enhancement requests.
- Follow up on pending insurer/TPA queries.
- Monitor patients nearing discharge.
- Coordinate discharge approvals.
- Check completeness of claim documentation.
- Submit final claims promptly.
- Update the insurance claim tracking register/system.
- Follow up on outstanding claims and payments.
- Report important pending issues to the Insurance In-charge/Hospital Administrator.

1. Key Performance Indicators (KPIs)

The Insurance Claim Handler will be evaluated based on:




- Timeliness of pre-authorization submission.
- Percentage of cashless approvals obtained without delay.
- Time taken for discharge authorization.
- Percentage of claims submitted within stipulated timelines.
- Claim rejection rate.
- Claim deduction rate.
- Percentage of claims settled successfully.
- Average time taken for claim settlement.
- Reduction in avoidable deductions.
- Accuracy and completeness of documentation.
- Timely response to insurance/TPA queries.
- Amount of outstanding insurance receivables.
- Patient/attender satisfaction regarding insurance coordination.

1. Essential Skills & Competencies

- Good knowledge of hospital insurance and TPA procedures.
- Basic understanding of medical terminology and hospital procedures.
- Good knowledge of hospital billing and documentation.
- Strong communication and interpersonal skills.
- Ability to coordinate effectively with doctors, patients, TPAs and insurance companies.
- Good computer skills, including MS Office/hospital information systems.
- Strong follow-up and organizational skills.
- Attention to detail.
- Ability to work under pressure and meet deadlines.
- Professional, courteous and patient-friendly approach.
- Ability to identify documentation gaps and potential claim issues proactively.

1. Educational Qualification & Experience

Minimum Qualification:
- Any graduate degree; preferably , BBA, BBM, Hospital Administration, Healthcare Management or related qualification.

Preferred Experience:
- 1–3 years of experience in hospital insurance/TPA/cashless desk/medical billing.
- Experience in a multispeciality hospital is preferred.
- Familiarity with major insurance companies and TPAs will be an advantage.

1. Professional Conduct

The Insurance Claim Handler shall:
- Maintain strict confidentiality of patient and financial information.
- Avoid making unauthorized commitments to patients or insurance companies.
- Never alter or fabricate medical or financial documentation.
- Maintain professional communication with insurance companies, TPAs, patients and hospital staff.
- Escalate unusual, disputed or high-value claims to the appropriate authority.
- Follow hospital policies, applicable insurance requirements and regulatory standards.

1. Authority & Escalation

The Insurance Claim Handler may independently coordinate routine insurance activities but shall escalate:
- High-value claims
- Major claim deductions
- Claim rejections
- Suspected fraudulent claims
- Repeated TPA/insurance disputes
- Significant discrepancies between approved and actual billing
- Patient complaints relating to insurance coverage
- Cases requiring management intervention

to the Insurance In-charge / Hospital Administrator.
1. Overall Responsibility

The Insurance Claim Handler is responsible for ensuring a smooth, transparent and timely insurance journey for the patient while protecting Shri Sai Hospital from avoidable claim deductions, delays and revenue loss. Pay: ₹10,000.00 - ₹15,000.00 per month

Benefits

- Flexible schedule

Work Location: In person

📌 Insurance Claims Handler (Ponmeni)
🏢 Shri Sai Multi Speciality Hospital
📍 Ponmeni