TPA Operations Coordinator

Experience

Minimum 2–5 years of relevant experience in handling Private TPA, and Ayushman Bharat PM-JAY claims in a hospital.

Educational Qualification

• Graduate in any discipline (Healthcare/Hospital Management preferred)
• Computer proficiency certification will be an added advantage.

Key Responsibilities

• Manage complete cashless processing for Private TPA, Insurance Companies, and Ayushman Bharat (PM-JAY) patients.
• Process pre-authorizations, enhancements, discharge approvals, final bill submissions, claim settlements, and query management within prescribed timelines.
• Ensure accurate documentation and compliance with PM-JAY and insurance guidelines.
• Handle the PM-JAY BIS, TMS, HEM, and other relevant portals efficiently.
• Coordinate with treating doctors, nursing staff, billing department, and insurance representatives for timely approvals.
• Verify medical records, treatment protocols, ICD coding (basic knowledge preferred), investigation reports, and discharge summaries before claim submission.
• Follow up on pending authorizations, deficiencies, rejected claims, and payments.
• Maintain daily MIS reports, claim status trackers, pending approvals, and revenue reports.
• Ensure maximum approval rates with minimum claim rejections.
• Coordinate with TPAs, insurance companies, PM-JAY authorities, and government agencies regarding claim-related matters.
• Train and guide internal staff regarding documentation requirements and panel compliance.
• Ensure confidentiality of patient records and comply with hospital policies.

Required Skills

• Proven experience in managing Private TPA and Ayushman Bharat (PM-JAY) operations.
• Thorough knowledge of:
• Pre-Authorization
• Enhancement Requests
• Final Authorization
• Claim Submission
• Query Resolution
• Claim Reconciliation
• Strong technical knowledge of PM-JAY portals and workflows, including package selection, documentation requirements, transaction management, and claim processing.
• Excellent knowledge of medical terminology, clinical documentation, investigations, operative notes, discharge summaries, and treatment protocols.
• Excellent computer skills with advanced proficiency in Microsoft Excel, Word, email, and hospital management software (HIS).
• Ability to prepare reports using Excel (VLOOKUP/XLOOKUP, Pivot Tables, Filters, Basic Formulas, etc.).
• Strong communication, coordination, and negotiation skills.
• Ability to work under pressure and meet strict turnaround times.

Preferred Candidate Profile

• Experience in a NABH/CGHS/PM-JAY empanelled multispecialty hospital will be preferred.
• Knowledge of government healthcare schemes, insurance regulations, and claim compliance.
• Positive attitude, problem-solving ability, and excellent team coordination.