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Tpa Executive

1 month ago

Gorakhpur Uttar Pradesh, India PLATINUM HOSPITAL Full time

Claims Management:
Coordinate with TPAs for pre-authorization, cashless treatment approvals, and claims processing.
Verify documents and ensure accurate and timely submission of claims.
Track claim statuses and follow up on pending or rejected claims.
Patient Coordination:
Guide patients on eligibility and processes for PMJAY and TPA-related services.
Ensure beneficiaries under PMJAY receive entitled treatment and services.
Address grievances related to insurance and scheme benefits.
Data Management:
Maintain accurate records of TPA claims and PMJAY patient data.
Regularly update databases with approvals, discharges, and claims status.
Liaison Work:
Act as a bridge between the hospital, insurance companies, and government authorities.
Communicate with TPAs for policy updates and process changes.
Collaborate with the PMJAY nodal agency for compliance and reporting.
Compliance and Reporting:
Ensure adherence to government and TPA guidelines.
Prepare and submit periodic reports on claims, reimbursements, and patient benefits.
Ensure alignment with PMJAY and IRDAI (Insurance Regulatory and Development Authority of India) standards.
Awareness and Training:
Educate hospital staff and patients on TPA and PMJAY policies and benefits.
Conduct workshops or sessions to improve understanding of processes among stakeholders.
Skills and Competencies
Strong understanding of health insurance policies, PMJAY guidelines, and claim processing.
Excellent communication and negotiation skills.
Proficiency in data management and healthcare software.
Problem-solving and grievance-handling abilities.
Knowledge of regulatory and compliance requirements.

**Qualifications**:
Bachelor's degree in any field (preferably in healthcare, business administration, or insurance).
Knowledge or experience in health insurance, TPA, or government health schemes like PMJAY.
Familiarity with hospital operations is a plus.
Work Environment
Working closely with hospital administrators, patients, and external agencies.
Involves desk work, as well as coordination across departments and external parties.
This role is crucial in ensuring smooth access to healthcare services for insured and PMJAY beneficiaries while optimizing hospital revenue through efficient claims processing.

Pay: ₹18,000.00 - ₹25,000.00 per month

Schedule:

- Day shift

**Experience**:

- total work: 2 years (required)

Work Location: In person