Tpa Medical Officer

**Key Responsibilities**:
**1. Pre-authorization & Claim Management**:

- Review and validate pre-authorization requests as per medical necessity and insurance policy guidelines.
- Prepare and submit pre-authorization forms with accurate diagnosis, procedure codes, and estimated costs.
- Monitor approval status and follow up with TPAs for timely authorization.
- Scrutinize final bills, discharge summaries, and investigation reports before claim submission.

**2. Coordination & Communication**:

- Coordinate with consultants, nursing staff, and billing teams for complete documentation.
- Communicate with TPA coordinators and insurance executives for approvals, queries, or discrepancies.
- Handle patient or attendant queries related to insurance coverage and approvals.

**3. Documentation & Compliance**:

- Ensure all treatment notes, prescriptions, and reports are attached to claims.
- Maintain accurate and complete records of all TPA-related activities.
- Verify compliance with IRDA and hospital policies regarding TPA operations.

**4. Medical Review**:

- Evaluate the medical justification of treatment plans and hospital stay.
- Cross-check diagnosis and procedure coding (ICD/CPT) to avoid rejections.
- Assist in preparing medical justifications for claim rejections or queries.

**5. Reporting**:

- Prepare daily/weekly/monthly MIS reports on TPA cases, pending approvals, and claim settlements.
- Track and analyze TPA claim rejection trends to improve documentation accuracy.

**Skills & Competencies**:

- Strong medical assessment and analytical skills.
- Good communication and coordination abilities.
- Knowledge of insurance policies and hospital billing systems.
- Attention to detail and documentation accuracy.
- Proficiency in MS Office and HIS (Hospital Information System).

**Qualifications & Experience**:

- **Education**: MBBS / BAMS / BHMS (MBBS preferred).
- **Experience**: Minimum 1-3 years in hospital TPA department / insurance claim processing / utilization review.
- **Knowledge**:

- Medical coding (ICD, CPT).
- TPA software systems and hospital billing.
- Insurance claim workflow and pre-authorization process.

**Job Types**: Full-time, Permanent

Pay: ₹30,597.71 - ₹45,512.63 per month

**Benefits**:

- Cell phone reimbursement
- Leave encashment
- Paid sick time
- Paid time off
- Provident Fund

**Education**:

- Bachelor's (preferred)

**Experience**:

- TPA: 2 years (preferred)

Work Location: In person