Head TPA & Claims Process Controller & Audits

Designation: Head TPA & Claims Process Controller & Audits

Location: Thane Corporate Office

Department: TPA & Claims

Qualification: BAMS/BHMS/MBBS with Post Graduation / Healthcare Management

Professional Experience: 3+ years of Experience in a tertiary care hospital or Health Insurance sector

Main Objective of the Role:

To Ensure compliance to complete End to End claim processing, disbursement and settlement for All insurance and corporate Patients

Key Responsibilities

Medical Claims Compliance & Processing Oversight

• Ensure 100% compliance in claims processing through the IHX portal.
• Monitor the complete end-to-end lifecycle of claims management, including disbursal and settlement.
• Supervise and review daily, weekly, and monthly claims data: claims raised, under query, pending/disputed, and ageing analysis.
• Assist local TPA teams in resolving stuck or disputed claims.
  
• Ensure claims are settled in line with the agreed MoU with partners and corporates.
• Monitor and control disallowances and short payments after final approvals.
• Supervise the claim settlement process within the HMIS system.
• Liaise, engage, and coordinate with insurance companies and TPA partners.

Claims Audit & Quality Assurance

• Perform detailed audits of medical claims to ensure accuracy and integrity.
• Review and verify diagnosis codes, treatment plans, and medical necessity.
• Identify and rectify errors, discrepancies, or potential fraud in claims submissions.
• Prepare comprehensive audit reports with findings, recommendations, and corrective actions.
• Maintain accurate and complete records of audits and corrective measures.

Process Improvement & Compliance

• Develop and implement efficient claims processing procedures and controls to enhance accuracy and operational efficiency.
• Monitor and analyze claims trends and processing metrics to identify improvement areas.
• Ensure adherence to regulatory requirements and best practices.
• Collaborate with internal teams to refine policies and procedures for claims adjudication.
• Assist in the development and review of medical policies, clinical guidelines, and criteria for adjudication.

• Provide clinical expertise and guidance for handling complex medical cases and claims.
• Conduct training sessions for claims processors on medical terminology, coding, and best practices.
• Stay updated with medical advancements, coding updates, and regulatory changes to support continuous process improvement.

MIS Reports

1. Claim Intake Summary Report
2. Claims Under Process
3. Query & Dispute Log
4. Claims Workflow Tracker
5. Aging Analysis Report
6. Short Payment & Disallowance Summary
7. Claims Settlement Dashboard
8. TPA/Insurer Performance Report
9. Compliance Scorecard
10. Financial Impact Report
11. High-Value Claims Review
12. Clinical Coding Accuracy Report

Note: Interested candidates can email the resume on [HIDDEN TEXT]