Job Summary The TPA Executive facilitates smooth cashless and reimbursement insurance workflows for patients undergoing ophthalmic treatments and surgeries (such as cataract, retina, glaucoma, and corneal procedures). The role requires accurate documentation, strict adherence to turnaround times (TAT), and close coordination with clinical and billing teams to ensure timely claim settlement.
Key Responsibilities
Check patient policy validity, sum insured, sub-limits (especially for cataract/intraocular lenses), and waiting periods prior to admission.
Clearly explain cashless procedures, required documents, co-payments, deductibles, and non-payable consumables to patients and attendants.
Manage empanelment workflows and documentation for corporate tie-ups and government schemes (e.g., CGHS, ECHS, state health schemes)
Follow up proactively on pending approvals and raise enhancement requests if surgical plans or lens costs change.
Address medical or administrative queries raised by TPAs promptly by coordinating with treating ophthalmologists.
Assist non-network or cash-paying insured patients by providing attested medical records and claim forms for post-discharge reimbursement.
Coordinate with the billing department to ensure hospital tariffs match agreed TPA package rates and deductions are accurately recorded.
- Education: Bachelor’s degree in any discipline (Healthcare Administration, Hospital Management, or Commerce preferred).
- Experience: 2–3 years in hospital TPA operations or medical insurance billing; prior experience in an eye hospital is a robust advantage.