Cloudnine hospital is hiring For TPA executive.

Designation: Pre-Authorization, Final Bill & Discharge Summary Validation Executive

Role Purpose

To ensure accurate, compliant, and timely submission of insurance claims by validating pre-authorizations, final bills, discharge summaries, tariffs, approvals, and supporting documents, thereby minimizing claim rejections, revenue leakage, and manual bill edits.

Key Responsibilities

• Validate Pre-Authorization (PA) requests before submission to Insurance Companies/TPAs.
• Verify patient KYC, insurance card, ID proof, diagnosis, room category, package applicability, LOS, and supporting clinical documents.
• Ensure all required investigations, consultation records, and justification letters for package deviations are available.
• Review final bills to ensure charges, packages, tariffs, discounts, and approvals are applied as per insurer/TPA agreements.
• Validate approval letters and coordinate with IP Managers, Billing Teams, and Insurance/TPAs for necessary corrections.
• Calculate and verify non-medical expenses (NMEs), non-payable items, and patient liabilities, and communicate collection requirements to IP teams.
• Cross-check diagnosis, procedures performed, billing entries, and discharge summaries for accuracy and compliance.
• Coordinate resolution of insurer/TPA queries and ensure timely claim submissions.
• Monitor Preauth submissions through IHX and other designated portals.
• Conduct pre-discharge billing audits to identify and rectify discrepancies before claim submission.
• Maintain compliance with insurer guidelines, hospital policies, and audit requirements.
• Generate exception reports and recommend process improvements to reduce claim deductions and manual bill modifications.

Key Performance Indicators (KPIs)

• Reduction in manual bill edits.
• Reduction in Preauth rejections and deductions.
• First-time-right Preauth submission rate.
• Accuracy of tariff, package, and approval validation.
• Timely submission of Preauth within SLA.
• Reduction in post-discharge billing corrections.

Expected Outcome

Ensure accurate claim processing, improve claim realization, minimize billing errors and deductions, strengthen compliance, and enhance overall insurance revenue management.