Executive Director of Healthcare Operations

1 week ago

Mumbai, Maharashtra, India Talent Destination Full time

**Job Summary**

Talent Destination is seeking a highly experienced Executive Director of Healthcare Operations to drive our trust and safety strategy, overseeing hospital coordination, insurance claim processing, and TPA operations. The ideal candidate will have a strong background in setting and running processes in the healthcare insurance domain, including patient admission and discharge, billing verification, risk mitigation, and fraud prevention.

Hospital Coordination:

  • Manage relationships with hospital billing departments to ensure seamless service coordination.
  • Oversee admission, discharge, and cost verification processes, ensuring adherence to CarePal's pricing agreements.
  • Lead efforts to streamline billing accuracy, end-to-end claim processing, optimize reconciliation processes, and enhance the patient experience.

Billing Verification & Reconciliation:

  • Conduct cost verification and reconciliation with hospital billing & Finance teams to prevent discrepancies and ensure adherence to agreed rates.
  • Develop structured reconciliation processes to accurately track and validate patient costs.
  • Identify opportunities for cost-saving and process improvement in billing workflows.

Patient Journey & Health Insurance Coordination:

  • Oversee the full patient journey from admission through discharge, ensuring compliance with healthcare insurance guidelines.
  • Coordinate with TPA and hospital teams for seamless admission, discharge, and insurance claim processes.
  • Ensure all insurance-related processes are efficient, accurate, and meet regulatory standards.

Patient Background Verification:

  • Manage patient background verification processes, ensuring accurate information validation.
  • Implement standardized procedures for patient verification, proactively identifying and resolving discrepancies.
  • Maintain high standards of trust and safety by ensuring complete and accurate patient onboarding till claim settlement.

TPA Operations & Insurance Claim Management:

  • Lead TPA operations, focusing on claims processing, insurance documentation, and patient eligibility verification.
  • Collaborate with TPA providers and insurance companies to ensure streamlined workflows and compliance.
  • Enhance TPA operations by optimizing processes, reducing processing times, and improving patient satisfaction.

Fraud Prevention & Risk Management:

  • Oversee insurance claim processes, implementing fraud detection and prevention strategies.
  • Regularly monitor and audit for fraud risks, addressing any detected anomalies.
  • Maintain high standards of trust by managing systems that prevent fraudulent activities in patient billing and insurance claims.

Policy Development & Compliance:

  • Develop policies to uphold trust and safety in patient operations, aligning with healthcare and insurance standards.
  • Regularly update policies to comply with regulatory changes and industry trends.
  • Ensure strict adherence to data privacy laws, healthcare regulations, and insurance guidelines across all operations.

Risk Analysis & Escalation Management:

  • Conduct risk assessments to identify potential issues, especially in hospital coordination, TPA processes, and patient verification.
  • Lead escalation protocols to resolve trust and safety concerns promptly in collaboration with hospital and insurance partners.
  • Regularly review processes to minimize risk and maintain high standards of operational integrity.

Data Analysis & Reporting:

  • Utilize data analytics to track operational trends, identify areas for improvement, and monitor patient satisfaction.
  • Prepare regular reports on trust and safety metrics, incident outcomes, and fraud prevention results for executive leadership.
  • Use data insights to refine processes, enhance efficiency, and guide strategic decision-making.

Team Leadership & Development:

  • Lead and mentor the Trust & Safety team, fostering a culture of accountability, integrity, and excellence.
  • Ensure team members are well-trained in trust and safety protocols, billing verification, and insurance claims processes.

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