Assistant Manager - Operations

Key Skills

• Strong knowledge of TPA and health insurance processes
• Cashless authorization and claim management
• Knowledge of pre-authorization, discharge approval, and reimbursement claims
• Coordination with Insurance Companies and TPAs
• Hospital billing and insurance documentation
• Team handling and people management
• Strong communication and interpersonal skills
• Problem-solving and escalation management
• Negotiation and stakeholder management
• Knowledge of healthcare/insurance regulations and SOPs
• MIS, reporting, and data analysis
• Good working knowledge of MS Excel, Word, and PowerPoint
• Ability to work under pressure and meet timelines

Key Job Responsibilities

1. TPA & Insurance Operations

• Manage day-to-day TPA and insurance-related activities.
• Coordinate with TPAs and insurance companies for cashless approvals and claim processing.
• Monitor pre-authorization, enhancement requests, discharge approvals, and final settlements.
• Ensure timely submission and processing of required documents.

2. Claims Management

• Monitor cashless and reimbursement claims.
• Identify discrepancies, documentation gaps, and claim-related issues.
• Coordinate with billing, medical, nursing, and other departments for claim resolution.
• Follow up on pending and rejected claims and ensure timely closure.

3. Stakeholder Coordination

• Maintain effective relationships with TPAs, insurance companies, patients, doctors, and hospital departments.
• Handle escalations related to approvals, deductions, claim settlement, and billing.
• Ensure timely communication and resolution of stakeholder concerns.

4. Team Management

• Supervise and guide the TPA/insurance team.
• Allocate work and monitor team performance.
• Conduct regular reviews and provide guidance/training to team members.
• Ensure adherence to departmental SOPs and turnaround times (TAT).

5. MIS & Reporting

• Prepare daily/weekly/monthly TPA and insurance reports.
• Monitor pending approvals, claims, deductions, rejections, and outstanding cases.
• Analyze operational data and identify areas for improvement.
• Present performance reports to management.

6. Compliance & Process Improvement

• Ensure compliance with hospital policies, insurance guidelines, and applicable regulatory requirements.
• Maintain proper documentation and records.
• Identify process gaps and implement corrective measures.
• Work toward improving TAT, claim realization, and patient satisfaction.

Key Performance Indicators (KPIs)

• Cashless approval TAT
• Claim settlement TAT
• Pending/rejected claim reduction
• Claim realization percentage
• Documentation accuracy
• Escalation resolution TAT
• Team productivity
• Patient/stakeholder satisfaction
• Compliance with SOPs

Preferred Candidate Profile

The ideal candidate should have strong knowledge of healthcare insurance/TPA operations, excellent coordination skills, and the ability to manage a team and resolve complex claim-related issues. Candidates with BDS/BAMS and MBA/MHA qualifications and relevant healthcare/TPA experience will be preferred.