1. Key Job Responsibilities

A. TPA Coordination and Management
- Manage day-to-day operations of the TPA and insurance department.
- Coordinate with TPAs, insurance companies, and other empanelled organizations.
- Maintain effective communication with insurance representatives regarding patient cases, approvals, queries, and payments.
- Handle escalations related to delayed approvals, claim rejections, and pending settlements.
- Maintain updated records of empanelment agreements, MOUs, rate charts, and insurance policies.

B. Pre-Authorization and Cashless Approval
- Ensure timely submission of pre-authorization requests for eligible cashless patients.
- Verify patient insurance details, policy validity, eligibility, and required documents.
- Monitor pre-authorization status and follow up for pending approvals.
- Coordinate with treating doctors for medical justifications, investigation reports, and treatment plans.
- Ensure timely submission of enhancement requests and final authorization requests.
- Communicate approval status and insurance-related requirements to the billing department and concerned staff.

C. Claims Processing and Documentation
- Ensure accurate preparation and submission of insurance claims.
- Verify claim documents, including:
- Pre-authorization and approval letters
- Admission notes and clinical records

- Investigation reports
- Doctor's prescriptions and progress notes

- Discharge summaries
- Final bills and detailed bill breakups
- Pharmacy bills and procedure-related documents
- Ensure claims are submitted within the prescribed timelines.
- Maintain proper records of submitted, pending, queried, approved, and rejected claims.





D. Query Management and Claim Reconciliation
- Respond to TPA and insurance company queries within the specified deadlines.
- Coordinate with doctors, nursing staff, medical records, pharmacy, and billing teams to collect the required documents.
- Follow up on rejected, partially approved, and underpaid claims.
- Compare final approved amounts with actual settlement amounts.
- Identify deductions, short payments, and discrepancies in insurance settlements.
- Submit reconsideration requests or appeals with appropriate supporting documents.

E. Payment Follow-Up and Outstanding Management
- Maintain an updated statement of outstanding insurance claims.
- Follow up regularly with TPAs and insurance companies for pending payments.
- Prepare ageing reports for outstanding claims.
- Track claim-wise submitted amounts, approved amounts, deductions, and received payments.
- Coordinate with the accounts department to reconcile insurance receipts.
- Escalate long-pending payments to hospital management.

F. Empanelment and Rate Revision
- Coordinate current empanelment applications with TPAs, insurance companies, and corporate clients.
- Submit hospital documents, tariff details, bank details, registrations, and other required records.




- Follow up for empanelment approval, renewals, and agreement execution.
- Review existing package rates and identify procedures with inadequate reimbursement.
- Prepare and submit rate revision requests with supporting cost justifications.
- Follow up for revised rate charts, updated MOUs, and confirmation of applicable tariffs.

G. Team Management and Interdepartmental Coordination
- Supervise TPA executives and ensure proper distribution of work.
- Monitor staff performance, productivity, and adherence to claim submission timelines.
- Coordinate with doctors, reception, admission, billing, pharmacy, nursing, medical records, and accounts departments.
- Train staff on insurance procedures, documentation requirements, and TPA guidelines.
- Resolve operational issues related to cashless patients and insurance billing.

H. Reporting and Compliance
- Prepare daily, weekly, and monthly TPA performance reports.
- Maintain accurate and confidential patient and insurance records.
- Ensure compliance with hospital policies, insurer requirements, and applicable regulations.
- Maintain records for insurance audits and internal inspections.
- Report major claim rejections, financial losses, delayed approvals, and pending settlements to management.

Main Objective of the Position The primary objective of the TPA Incharge is to ensure smooth cashless treatment coordination, accurate insurance claim processing, timely reimbursement, effective outstanding payment recovery, and proper management of TPA and insurance-related operations while minimizing revenue loss for the hospital.

📌 Walk-in || Tpa Manager (Dhanbad)
🏢 Sangeeta Healthcare
📍 Dhanbad