Job title : Senior Executive (Credit processing)

Department : Central Corporate Billing

Reports to : Head of Department

Work category : Backend processing Team

Duty Roster : Multishift - Rotation duty - Day/Night/Sundays

Activities : Authorisations, Dispatch, settlement follow ups, Handling Query, patient/Customer support, reports, attend related inhouse and external meetings/requirements

Profile : Backend Support executive handling large patient volume from multiple hospital units with support from billing and admission desk. Be ready to travel to individual hospital units to provide hands-on support during peak periods, system implementations, or to investigate and resolve specific issues.

Job summary : Responsible for the end-to-end management of cashless and claims from diverse sources. This includes private insurance companies, Third-Party Administrators (TPAs), various government health schemes(State and central), and corporate tie-ups. The role involves verifying eligibility, ensuring correct documentation, processing claims accurately, managing denials, dispatch and settlements.

Key responsibilities

1. Pre-authorization and eligibility verification

- Insurance and TPA patients: Verify patient insurance coverage, eligibility, and benefits before or at the time of processing. Contact insurance companies/SPOC’s to obtain precertification or prior authorization for procedures and services as required. Communicate with patients to inform them of their coverage details, financial responsibilities (e.g., co-pays and deductibles), and any payment plans.
- Government scheme patients: Confirm eligibility for schemes like the Central Government Health Scheme (CGHS), Ayushman Bharat (PM-JAY), or state-specific schemes (e.g., CMCHIS) and obtain necessary approvals. Aware of the respective billing process and codes as per the specific schemes.
- Corporate patients: Verify patient eligibility based on the hospital's corporate tie-up agreements.

2. Documentation and submission

- Accurately enter and process large volumes of patient admission data, billing details, and discharge summaries from various units into respective units customer portals or mails.
- Conduct thorough checks of admission and billing documents, including insurance details, patient demographics,



and medical records, to identify and correct discrepancies before claims submission
- Compile and review all required medical and billing documents for each claim type.
- Ensure accurate and compliant medical coding (e.g., ICD-10, CPT) for all diagnoses and procedures, following the specific guidelines of the payer.
- Submit claims electronically or manually to the respective insurance company, TPA, or government and corporate portals within defined timelines.

3. Billing and processing

- Prepare/Verify/Generate accurate bills according to the specific tariff and billing rules of the insurance plan, government scheme, or corporate agreement.
- Verify payments, rejections, and denials received from all payers into the hospital's billing system.
- Reconcile accounts to ensure all payments are correctly received without any deduction.

4. Denial management and appeals

- Investigate the reasons for denied or underpaid claims from all sources, including denials based on policy exclusions or package rates.
- File timely and well-documented appeals to insurance companies, TPAs, and government scheme offices.
- Follow up rigorously on all approvals and outstanding claims to ensure a high rate of approval/collection.
- Identify denial trends to suggest process improvements and minimize future queries and rejections.

5. Communication and collaboration

- Act as the primary point of contact for patients (Backend support), TPAs, corporate HR, and government scheme representatives for all billing and claims-related inquiries.
- Coordinate with internal departments, such as clinical teams, patient admissions and billing to ensure accurate and timely documentation for claims
- Provide support and guidance to colleagues on best practices for claims processing and patient billing.

6. Compliance and reporting

- Prepare and submit daily, weekly,



and monthly reports on key metrics such as admission volumes, billing accuracy, and process turnaround times. Generate regular reports on approval/claims status, payment trends, and outstanding receivables for management.
- Analyze backend data to identify trends, pinpoint common errors, and suggest improvements to enhance efficiency across all units
- Maintain updated knowledge of regulations, policy changes, and scheme guidelines for all types of payers.
- Generate and maintain accurate records of processed claims and provide reports on claims status and performance metrics to management.
- Regular meetings with operations and billing teams, focus on improving the credit bill process, analyzing the reasons for disallowances, and ensuring associated deliverables are met effectively.

Qualifications and requirements

Experience:

- Proven experience in large volume medical claims processing, insurance verification, and hospital billing with specific experience handling claims from multiple payer types (e.g., TPAs, government schemes, corporate, etc).
- Knowledge of medical terminology, medical billing cycles, and health insurance regulations.
- Aware of Package Medical Billing and Coding (e.g., CGHS, ECHS, etc) is often preferred.

Skills:

- Process expertise: Deep understanding of hospital admissions, billing, and revenue cycle management.
- Analytical skills: Ability to analyse complex claims data, identify discrepancies, and solve problems effectively. Ability to process large volumes of data and identify trends.
- Attention to detail: Meticulous and accurate in reviewing claims and entering data.
- Communication skills: Excellent written and verbal communication for interacting with patients, insurance companies, and staff.
- Technical proficiency: Proficient in medical billing software, electronic health records (EHR), and Microsoft Office Suite.
- Organizational skills: Robust ability to manage multiple tasks, prioritize workload, and meet deadlines.
- Customer service: A patient-centric mindset with empathy for individuals facing complex healthcare situations.
- Flexibility: Must be able to adapt to changing situations and travel to different hospital units on short notice.

📌 Corporate Billing Executive (Tiruchirappalli)
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