TPA Executive

Organization: Kalyanam Karoti Eye Institute, Kalyanam Karoti, Mathura
Department: TPA, Insurance & Billing
Job Type: Full-Time
Location: Govardhan Road, Mathura, Uttar Pradesh

1. Job Summary

We are looking for a responsible and detail-oriented TPA Executive to manage health insurance, Third Party Administrator (TPA), and cashless treatment-related activities at the eye hospital. The candidate will coordinate with patients, insurance companies, TPAs, government health schemes, and hospital departments to ensure smooth pre-authorization, claim submission, and settlement processes.

2. Key Responsibilities

A. Insurance & TPA Coordination

- Coordinate with insurance companies, TPAs, and authorized government health schemes.
- Verify patient insurance policies, eligibility, coverage, and required documents.
- Explain cashless treatment procedures and documentation requirements to patients and their attendants.
- Maintain updated records of empanelled insurance companies and TPAs.

B. Pre-Authorization & Cashless Treatment

- Prepare and submit pre-authorization requests for eligible patients.
- Coordinate with doctors and concerned departments to obtain medical notes, investigation reports, and treatment plans.
- Follow up on pending approvals, queries, enhancements, and re-authorizations.
- Communicate approval status and applicable financial requirements to patients.

C. Claim Processing & Settlement

- Prepare and submit complete insurance claims within prescribed timelines.
- Verify bills, discharge summaries, prescriptions, investigation reports, and other supporting documents.
- Respond to insurance company queries and coordinate claim corrections.
- Track claim status, payment realization, deductions, rejections, and outstanding amounts.




- Assist in resolving rejected or partially settled claims and preparing appeals where appropriate.

D. Government Health Schemes

- Coordinate eligible patient cases under applicable government healthcare schemes, such as Ayushman Bharat PM-JAY, where the hospital is empanelled.
- Verify beneficiary eligibility and scheme-specific requirements.
- Ensure proper documentation, authorization, package compliance, and claim submission.
- Coordinate with scheme authorities for queries, audits, and settlement follow-ups.

E. Patient Support & Billing Coordination

- Guide patients and attendants regarding insurance procedures and documentation.
- Coordinate with the billing, admission, discharge, medical records, and accounts departments.
- Explain approved coverage, exclusions, co-payments, and non-payable expenses as per policy terms.
- Maintain professional communication and confidentiality of patient information.

F. Documentation & Reporting

- Maintain records of pre-authorizations, submitted claims, approvals, rejections, and settlements.
- Prepare daily and monthly reports on claim status, pending cases, outstanding amounts, and collection performance.
- Ensure accurate data entry and proper maintenance of physical and digital files.
- Support internal audits and insurance/TPA inspections.

3. Educational Qualification

- Graduate in any discipline; preference for Healthcare Administration, Hospital Management, Commerce, or related fields.




- Knowledge of medical billing, health insurance, and TPA procedures is preferred.
- Basic computer knowledge and proficiency in MS Excel are essential.

4. Experience

- 1–3 years of experience in TPA, medical insurance, hospital billing, or cashless claim processing preferred.
- Experience in an eye hospital or multispecialty hospital will be an added advantage.
- Freshers with relevant training and strong communication skills may also be considered.

5. Required Skills

- Knowledge of insurance documentation and claim procedures.
- Good communication and coordination skills.
- Attention to detail and accuracy in documentation.
- Proficiency in MS Office and hospital management software.
- Ability to follow deadlines and manage multiple claims.
- Patient-friendly attitude and professional conduct.

6. Key Performance Indicators (KPIs)

- Timely submission of pre-authorization requests and claims.
- Reduction in claim errors, rejections, and avoidable deductions.
- Timely follow-up on outstanding claims and settlements.
- Accuracy and completeness of insurance documentation.
- Effective coordination with patients, insurers, TPAs, and hospital departments.

7. Reporting Structure

The TPA Executive will report to the Hospital Manager or designated Billing/Insurance Department Head.

8. How to Apply

Interested candidates may submit their updated CV mentioning their relevant experience, current salary, expected salary, and notice period.

Join Kalyanam Karoti Eye Institute and help patients access eye-care services through effective insurance and cashless treatment coordination.

Pay: ₹10,000.00 - ₹25,000.00 per month

Benefits:

- Flexible schedule

Work Location: In person

📌 TPA Executive (Mathura Nagar)
🏢 Kalyanam Karoti
📍 Mathura Nagar