Job Description: TPA Executive – Eye Hospital

Job Title: TPA Executive

Department: Insurance / TPA Department

Reporting To: TPA Manager / Centre Head

Industry: Ophthalmology

Employment Type: Full-Time

1. Job Summary

The TPA Executive is responsible for handling health insurance and Third-Party Administrator (TPA) activities, including patient insurance verification, pre-authorization, cashless hospitalization, claim documentation, and coordination with insurance companies and TPAs to ensure smooth and timely processing of patient claims.

The executive will coordinate with doctors, the billing department, medical records staff, and patients to facilitate cashless and reimbursement procedures for ophthalmic treatments and surgeries.

2. Key Roles and Responsibilities

A. Insurance and TPA Coordination

Coordinate with insurance companies, TPAs, and corporate clients regarding patient insurance coverage.

Verify patient insurance details, policy validity, eligibility, and available advantages.

Check coverage for ophthalmic procedures such as cataract surgery, retinal surgery, glaucoma treatment, and other eye-related procedures.

Explain insurance and cashless treatment procedures to patients and their attendants.

Maintain updated records of insurance companies, TPAs, and their respective policies.

B. Pre-Authorization and Cashless Approval

Process cashless treatment requests and pre-authorization forms.

Submit required medical documents, investigation reports, doctor prescriptions, and treatment plans to TPAs and insurance companies.

Follow up on pending approvals and coordinate for timely authorization.

Communicate approval, query, partial approval, or rejection status to the concerned departments and patients.

Coordinate with doctors to provide additional medical information when requested by the insurer.

C. Claim Processing and Documentation

Prepare and submit insurance claim documents accurately and within the prescribed timelines.

Ensure completeness of discharge summaries, operative notes, investigation reports, bills, prescriptions, and other supporting documents.

Review claim documents before submission to minimize errors and rejections.

Follow up on pending claims, queries, deductions,



and outstanding payments.

Maintain proper records of submitted claims, approved amounts, deductions, and claim settlement status.

D. Patient Coordination and Counselling

Assist patients and their families with insurance-related queries.

Explain the cashless process, policy limitations, non-payable items, co-payment, deductibles, and other applicable charges.

Inform patients about any amount payable by them, subject to hospital policy and insurer approval.

Provide guidance regarding reimbursement claims when cashless treatment is unavailable or not approved.

Ensure professional, courteous, and patient-friendly communication.

E. Coordination with Hospital Departments

Coordinate with the OPD, IPD, billing, accounts, medical records, nursing, and surgical teams.

Obtain the necessary medical documents and billing details for insurance processing.

Inform the billing department about approved insurance amounts and patient-payable balances.

Coordinate with the discharge team to ensure timely completion of insurance formalities.

Assist in resolving discrepancies between hospital bills and insurer-approved amounts.

F. Reporting and Record Maintenance

Maintain daily records of pre-authorization requests, approvals, pending cases, and claim submissions.

Prepare daily, weekly, and monthly reports on insurance cases and claim status.

Track outstanding insurance receivables and coordinate with the accounts department for reconciliation.

Maintain confidentiality of patient information and insurance documents.

Ensure compliance with hospital policies and applicable insurance documentation requirements.

3. Required Qualifications

Graduate in any discipline; a degree in Healthcare Administration, Hospital Management, or Commerce is preferred.

A diploma or certification in Medical Insurance, TPA Operations,



or Hospital Administration is an advantage.

Basic knowledge of health insurance, cashless hospitalization, and claim processing.

4. Required Experiencem

1–3 years of experience in TPA, health insurance, or hospital billing is preferred.

Experience in an eye hospital or ophthalmology setup will be an added advantage.

5. Required Skills

Good communication and interpersonal skills.

Knowledge of health insurance and cashless claim procedures.

Familiarity with hospital billing and medical documentation.

Basic computer knowledge, including MS Excel, Word, email, and hospital management software.

Strong follow-up, coordination, and problem-solving skills.

Attention to detail and accuracy in documentation.

Ability to manage multiple cases and work under time constraints.

Professional conduct and patient confidentiality.

6. Key Performance Indicators (KPIs)

The performance of the TPA Executive may be evaluated based on:

Timely submission of pre-authorization requests.

Turnaround time for obtaining cashless approvals.

Accuracy and completeness of claim documentation.

Reduction in claim rejections due to documentation errors.

Timely resolution of insurer queries.

Follow-up and reduction of pending insurance claims.

Coordination with the billing and accounts departments.

Patient satisfaction with insurance-related services.

7. Working Conditions

Work location: Arohi Eye Hospital, Andheri (West)

Working hours: 9 hrs per day ( including Lunch break).

May require coordination with patients, doctors, insurance companies, and TPAs during admission, surgery, and discharge.

The role may involve managing multiple insurance cases simultaneously.

8. Overall Responsibility

The TPA Executive is responsible for ensuring the smooth handling of insurance and cashless treatment procedures, accurate claim documentation, timely coordination with insurers, and effective communication with patients and hospital departments to support efficient hospital operations and minimize insurance-related delays.

Pay: ₹25,000.00 - ₹30,000.00 per month

Benefits:

- Cell phone reimbursement
- Provident Fund

Work Location: In person

📌 TPA Executive (Andheri West)
🏢 Aarohi eye hospital
📍 Andheri West