TPA Co-Ordinator

Qualification : Graduation from any stream

• Facilitate and manage the process of claim submissions and settlements between healthcare providers, insurers, and policyholders.
• Ensure the timely submission of claims, accurate documentation, and resolution of any discrepancies or issues in the claims process.
• Coordinate the approval and rejection process for medical claims, working closely with healthcare providers and insurance companies to ensure claims are processed smoothly.
• Track the status of claims and provide regular updates to relevant stakeholders (policyholders, healthcare providers, and insurance companies).

• Act as the primary point of contact for all TPA-related inquiries, ensuring effective communication between clients, insurance companies, healthcare providers, and policyholders.
• Provide support to healthcare providers and policyholders in understanding claim processes, insurance policies, and medical benefits.
• Facilitate the approval and authorization process for medical treatments, surgeries, and hospitalizations in coordination with insurers and healthcare providers.
• Resolve issues or complaints from stakeholders related to claims, authorizations, and reimbursements in a timely and professional manner.

• Ensure that all medical claims and documents are in line with the policies of the insurance company and adhere to legal and regulatory standards.
• Maintain up-to-date records of all claim submissions, rejections, authorizations, and payments.
• Review and verify that all required documentation for claims, including medical reports, bills, and receipts, is complete and accurate.
• Ensure that all TPA processes are in compliance with the contractual agreements between the company, clients, and service providers.

• Coordinate the pre-authorization process for hospital admissions, surgeries, and expensive medical treatments with the insurance provider and healthcare institutions.
• Work closely with medical providers to ensure that all necessary authorizations are obtained before treatments are provided, avoiding delays or issues with claims processing.

• Monitor and reconcile claims, ensuring that payments are made correctly and that any underpayments or overpayments are promptly addressed.
• Track payments made by insurance companies and verify the receipt of funds by healthcare providers.
• Maintain records of outstanding payments, follow up on delayed claims, and work with the finance team to resolve payment issues.

• Prepare and maintain regular reports on TPA activities, including claim status, payment tracking, and claims processed.
• Track key performance indicators (KPIs) related to claim settlement times, authorization approval times, and payment accuracy.
• Provide reports and updates to management on the status of claims and any ongoing issues with TPA processes.

• Provide excellent customer service to all stakeholders, ensuring that all TPA-related concerns and queries are addressed promptly and professionally.
• Educate policyholders on their coverage options, claim procedures, and the benefits available under their insurance policies.
• Resolve customer complaints and issues related to claims or TPA processes, maintaining a high level of customer satisfaction.

• Identify areas for improvement in the TPA process and recommend changes to enhance efficiency and service quality.
• Stay updated on industry trends, regulations, and best practices related to TPAs and claims management.
• Collaborate with internal teams and external partners to streamline TPA-related operations and minimize claim processing delays.

• A bachelor's degree in Healthcare Administration, Insurance, Business, or a related field.
• [Insert Years] years of experience in TPA coordination, healthcare claims management, or a related field.
• Knowledge of healthcare insurance policies, claims processes, and third-party administration.

• Strong communication skills, with the ability to interact with a variety of stakeholders, including healthcare providers, insurance companies, and policyholders.
• Strong organizational and time-management skills, with the ability to handle multiple tasks and priorities.
• Detail-oriented, with a keen eye for accuracy in documentation and claims processing.
• Knowledge of relevant regulations, including healthcare insurance standards and data privacy laws (e.g., HIPAA, GDPR).
• Problem-solving skills, with the ability to identify issues, investigate solutions, and resolve concerns efficiently.
• Ability to work independently as well as part of a team in a fast-paced environment.

• Customer-focused with a strong commitment to service excellence.
• Empathetic, with the ability to handle sensitive information and difficult situations with professionalism.
• High level of integrity and confidentiality when dealing with personal and medical data.
• Strong analytical skills to evaluate claim information and identify discrepancies or issues.
• Proactive attitude, with a focus on continuous improvement and achieving goals.