TPA Coordinator

Job Description

Position: Manager – TPA & Cashless Operations Location:

Saket Hospital, Prayagraj

Department:

Billing

 Reporting To:

Hospital Director

Job Summary

We are seeking an experienced and result-oriented Manager – TPA & Cashless Operations to oversee all insurance and cashless processes within the hospital. The role involves managing private insurance, TPAs, and government schemes like PMJAY (Ayushman Bharat) while ensuring smooth patient experience, accurate documentation, and timely claim settlements.

 Key Responsibilities

 TPA & Private Insurance Management

• Handle complete lifecycle of insurance claims
• Verify policy details and initiate Pre-Authorization (Pre-Auth)
• Coordinate with TPA/insurance companies for approvals
• Ensure smooth discharge process for cashless patients

 PMJAY (Ayushman Bharat) Operations

• Manage all activities related to PMJAY Scheme
• Patient eligibility verification and registration
• Package blocking and claim initiation
• Upload clinical documents on TMS Portal
• Ensure timely and successful claim submission

 Liaison & Empanelment

• Maintain strong coordination with TPA executives & Insurance companies
• Support management in empanelment & renewals
• Build professional relationships for smooth operations

 Query Management

• Coordinate with doctors and nursing staff
• Provide clinical justifications for insurance queries
• Ensure minimum claim rejection by proper documentation

 Claim Settlement & Recovery

• Monitor pending claims and receivables
• Track payments and ensure timely settlements
• Follow-up for delayed payments (beyond TAT)
• Ensure all approved claims are credited to hospital accounts

 Patient Counseling

• Explain cashless process, inclusions, and exclusions
• Maintain transparency with patients and attendants
• Handle disputes professionally during discharge

 Audit & Compliance

• Maintain documentation as per NABH & Insurance norms
• Ensure all records are audit-ready
• Support during internal and external audits

 Required Qualifications

• Graduate in any stream (Mandatory)
• MHA / MBA (Hospital Administration) preferred
• Medical background (BAMS / BHMS / B.Sc Nursing) preferred

 Experience Required

• Minimum 3–5 years of experience in hospital TPA/cashless department
• Experience in handling both Private Insurance & PMJAY Scheme

 Key Skills

• Strong knowledge of TPA & Insurance processes
• Expertise in PMJAY (TMS Portal)
• Good command over MS Excel & reporting
• Excellent communication & coordination skills
• Strong negotiation & problem-solving ability

 Key Performance Indicators (KPIs)

• High claim approval ratio with minimum rejection
• Reduced Pre-Auth TAT (Turnaround Time)
• Faster Discharge to Claim Submission time
• Timely recovery of payments (especially >45 days pending)

 Salary

 ₹30,000 – ₹40,000 per month (Based on experience & performance)