TPA Co-ordinator (ESIC)

Key Responsibility Areas (KRAs) TPA Coordinator (ESIC Billing & Related Work)

1. ESIC Billing & Claims Processing:
   
• Manage end-to-end processing of ESIC patient admissions, treatment approvals, and claim submissions.
• Ensure accurate and timely submission of bills to ESIC authorities.
• Maintain updated knowledge of ESIC policies, tariffs, and documentation requirements.
2. Coordination with TPA & Insurance Authorities:
   
• Act as a liaison between the hospital, ESIC, and third-party administrators (TPAs).
• Follow up on pending claims and resolve discrepancies to ensure timely reimbursements.
• Handle pre-authorization requests, approvals, and claim adjudication queries efficiently.
3. Compliance & Documentation:
   
• Ensure all ESIC and TPA-related documentation is complete and accurate.
• Adhere to regulatory requirements and hospital policies concerning ESIC claim management.
• Maintain meticulous records of claims submitted, processed, and pending.
4. Patient Assistance & Grievance Handling:
   
• Guide patients and their families on ESIC benefits, eligibility, and claim procedures.
• Address and resolve patient grievances related to ESIC billing and insurance claims.
• Provide assistance in case of claim denials or delays.
5. Billing & Revenue Cycle Management:
   
• Collaborate with the finance and billing departments to ensure accurate billing and reconciliation.
• Monitor claim rejection trends and work towards process improvements to minimize revenue loss.
• Prepare and present periodic reports on ESIC claim status and financial recoveries.
6. Stakeholder Coordination & Process Improvement:
   
• Work closely with hospital administration, finance, and medical teams to streamline the ESIC billing process.
• Suggest improvements in TPA and ESIC claim workflows to enhance efficiency and reduce turnaround time.
• Conduct periodic training for hospital staff on ESIC claim handling and documentation requirements.
7. MIS & Reporting:
   
• Prepare and submit reports on ESIC billing, pending claims, and revenue generation.
• Maintain dashboards for tracking claims and ensuring timely follow-ups.
• Provide management with insights on key billing metrics and bottlenecks.

Performance Metrics:

• Turnaround time for ESIC claims submission and processing.
• Percentage of claims approved without queries or rejections.
• Amount of revenue recovered from ESIC claims.
• Patient satisfaction levels concerning ESIC claim handling.
• Compliance with ESIC documentation and regulatory requirements.

Preferred candidate profile:

• Qualifications: Master's in Hospital Administration( MHA) , MBA (Hospital Management)
• Experience: 3 - 7 years of Experience as TPA Manager in healthcare industry