A TPA (Third Party Administrator) & Government Portal Executive in the healthcare/hospital industry acts as the crucial link between hospitals, insurance companies (TPAs), and government health schemes (such as CGHS, ECHS, Ayushman Bharat PM-JAY, or state-specific schemes). This role ensures that patient admissions, cashless authorizations, and final bill settlements are processed efficiently through online portals to ensure timely revenue generation. Indeed +4Here is a detailed job description based on industry standards:

Core Responsibilities

• Portal Management: Handling end-to-end operations on various portals (e.g., Medi Assist, MDIndia, Vidal, CGHS, ECHS, Ayushman Bharat/PM-JAY) for empanelment, patient registration, and claim submission.
• Cashless Authorization: Submitting pre-authorization requests for inpatient (IPD) cases within the stipulated turnaround time (TAT) and coordinating with TPA doctors for approvals.
• Documentation & Billing: Reviewing, auditing, and submitting hospital bills, discharge summaries, and medical records to TPAs/Government bodies for approval.
• Liaisoning: Acting as the primary point of contact between the hospital's internal departments (billing, medical team) and TPA/Government representatives.
• Query Resolution: Promptly answering queries raised by TPAs/Government officials regarding denied or pending claims.
• Patient Counseling: Explaining coverage details, policy limits, and the status of cashless/reimbursement requests to patients and their families.
• MIS Reporting: Maintaining detailed trackers of all claims, including pending, approved, and rejected cases, and preparing daily/monthly reports for management.

Required Qualifications and Skills

• Education: Bachelor’s degree in Hospital Administration, Healthcare Management, Commerce, or related fields.
• Experience: 1–3 years of experience in TPA, insurance billing, or hospital empanelment, preferably with experience in CGHS, ECHS, or PM-JAY portals.
• Technical Skills: Proficiency in MS Office (especially MS Excel) and familiarity with Hospital Information Systems (HIS).
• Knowledge: Strong understanding of medical insurance policies, ICD coding (for medical procedures), and claim processes.
• Soft Skills: Excellent communication (verbal and written), negotiation, and analytical skills.

Key Performance Indicators (KPIs)

• Turnaround Time (TAT): Ensuring quick submission of requests and approvals.
• Claim Approval Rate: Minimizing claim rejections through accurate documentation.
• Outstanding Management: Reducing the amount of outstanding payments from TPAs/Government.

Working Conditions

• Type: Full-time, Permanent.
• Location: Primarily on-site at a hospital or diagnostic center.
• Shift: Often day shift, but may require flexibility for emergency cases.

Job Type: Full-time

Pay: ₹25,000.00 - ₹35,000.00 per month

Benefits:

• Leave encashment
• Provident Fund

Work Location: In person