TPA Coordinator

Position: TPA Coordinator

Department: Insurance / TPA / Billing Department

Reporting To: Hospital Administrator / Billing Manager / Finance Manager

Location: Hospital

Job PurposeThe TPA Coordinator is responsible for coordinating insurance and Third-Party Administrator (TPA) activities for patients, ensuring timely pre-authorisation, documentation, claim processing, discharge approvals, and settlement of insurance/TPA cases.

• Key ResponsibilitiesTPA & Insurance CoordinationCoordinate with various TPAs, insurance companies, patients, doctors, billing and hospital departments.
• Handle cashless and reimbursement-related insurance cases.
• Verify patient insurance/TPA eligibility and policy details.
• Pre-AuthorizationPrepare and submit pre-authorisation requests to the concerned TPA/insurance company.
• Ensure all required medical documents, investigation reports, treatment details and estimates are submitted accurately.
• Follow up regularly for approval, query resolution and enhancement requests.
• Patient Admission & DocumentationAssist patients and their attendants with insurance/TPA-related procedures.
• Collect and verify required documents such as insurance card, ID proof, policy details and other relevant records.
• Ensure proper documentation at the time of admission.
• Discharge & Final ApprovalCoordinate with the billing department and medical team for preparation of final bills and discharge summaries.
• Submit final bills and required documents to the TPA/insurance company for discharge approval.
• Follow up for final authorization and settlement.
• Claim ProcessingPrepare and submit complete claim documents within the prescribed timelines.
• Monitor pending, approved, rejected and query cases.
• Coordinate with TPAs for clarification and resolution of claim queries.
• Coordination with Hospital DepartmentsCoordinate with doctors, nursing staff, medical records, billing, pharmacy, diagnostic and other departments for required documents.
• Ensure timely availability of medical records and supporting documents.
• Follow-up & Record MaintenanceMaintain proper records of all TPA/insurance cases.
• Track pre-authorisations, enhancements, discharge approvals, claim submissions, settlements and outstanding claims.
• Maintain daily/monthly reports of TPA cases and pending claims.
• Query & Rejection ManagementIdentify reasons for claim queries, deductions or rejections.
• Coordinate with the concerned departments to provide appropriate clarification and supporting documents.
• Escalate unresolved issues to the reporting manager.
• Billing & Financial CoordinationCoordinate with the billing/finance team regarding approved amounts, deductions, patient liability and outstanding payments.
• Check TPA/insurance settlements against submitted claims and approved amounts.
• Assist in reconciliation of TPA receivables.

1. Compliance & Confidentiality

• Ensure compliance with hospital policies, insurance/TPA requirements and applicable procedures.
• Maintain confidentiality and security of patient and insurance-related information.
• Ensure accurate and timely documentation.
• Required QualificationsGraduate in any discipline; preferably BBA, B.Com, B.Sc., BAMS, Nursing, Healthcare Management or equivalent.
• Diploma/Certificate in Healthcare Management, Medical Billing, Insurance or TPA operations will be an advantage.
• ExperiencePreferably 1–3 years of experience in TPA/insurance coordination, hospital billing, cashless desk or healthcare administration.