Claim Processing Executive (Ayushman And Corporate)

Job Title

Claim Processing Executive (Ayushman and Corporate)

Location

Hospital based role

Department

TPA, Corporate Billing and Government Health Schemes

Job Purpose

To manage end to end processing of Ayushman Bharat PMJAY and corporate insurance claims, ensuring timely approvals, accurate documentation, compliance with scheme and insurer guidelines, and smooth coordination with internal and external stakeholders.

Key Responsibilities

• Handle beneficiary verification and registration under Ayushman Bharat PMJAY

• Process cashless and reimbursement claims for corporate and insured patients

• Prepare and submit pre authorization requests on Ayushman, TPA, and insurer portals

• Upload treatment details, medical documents, estimates, and bills accurately

• Track claim status from admission to final settlement

• Coordinate with doctors, billing team, nursing staff, and front office for documentation

• Scrutinize discharge summaries, operative notes, and final bills as per guidelines

• Handle queries, shortfalls, rejections, and resubmissions within timelines

• Follow up with TPAs, insurance companies, and Ayushman authorities for approvals and payments

• Maintain records of approved, pending, rejected, and settled claims

• Ensure compliance with PMJAY rules, insurer policies, and corporate agreements

• Support audits, inspections, and insurer visits

• Provide regular updates to seniors on claim status and bottlenecks

Required Skills and Knowledge

• Strong understanding of Ayushman Bharat PMJAY scheme

• Working knowledge of corporate insurance and cashless claim workflows

• Familiarity with TPAs and insurance company portals

• Basic knowledge of hospital billing, packages, and medical documentation

• Good computer skills and attention to detail

• Strong coordination and follow up skills

Educational Qualification

• Graduate preferred

• Diploma or certification in hospital administration or healthcare management is an advantage

Experience

• 1 to 3 years of experience in Ayushman and or corporate claim processing

• Freshers with relevant training may be considered

Reporting To

• Billing Manager or TPA Head

Key Performance Indicators

• Claim approval and settlement rate

• Turnaround time for pre authorization and final submissions

• Reduction in rejections and shortfalls

• Compliance with documentation and scheme guidelines

Work Environment

• Hospital based

• Full time role

• Process driven with high coordination