Manager Medical Operations & Insurance

Pacific World Foundation; New Delhi; On-site; INR 350,000 - 550,000; Full time

Job summary

Pacific World Foundation seeks a qualified clinical professional to manage cashless admissions, pre-authorisation, enhancements and discharge approvals within the hospital network. You will review medical records to ensure the clinical justification for insurance claims and collaborate with TPAs and insurers on queries, rejections and pending cases.

You will coordinate with consultants, RMOs, nursing, billing and other departments across OPD, IPD and Emergency, and conduct medical audits to

Qualifications

• Hospital-based clinical experience.
• Exposure to Insurance/TPA operations (preferred).
• Experience in cashless patient management, claim management and medical audits.
• Working knowledge of HIS/HMS.
• Strong communication, coordination and problem-solving skills.

Responsibilities

• Manage cashless admissions, pre-authorisation, enhancements and discharge approvals.
• Review medical records and ensure clinical justification for insurance claims.
• Coordinate with TPAs and insurers on queries, rejections and pending cases.
• Coordinate with consultants, RMOs, nursing, billing and other departments across OPD, IPD and Emergency.
• Conduct medical audits and support NABH compliance.
• Train doctors and staff on insurance documentation, and improve approval and discharge TAT.

Skills

Communication

Coordination

Problem-solving

Tools

HIS/HMS

Job description

Role & responsibilities

• Manage cashless admissions, pre-authorisation, enhancements and discharge approvals
• Review medical records and ensure clinical justification for insurance claims
• Coordinate with TPAs and insurers on queries, rejections, deductions and pending cases
• Coordinate with consultants, RMOs, nursing, billing and other departments across OPD, IPD and Emergency
• Conduct medical audits and support NABH compliance
• Train doctors and staff on insurance documentation, and improve approval and discharge TAT

Who we are looking for:

• Hospital-based clinical experience
• Exposure to Insurance/TPA operations (preferred)
• Experience in cashless patient management, claim management and medical audits
• Working knowledge of HIS/HMS
• Strong communication, coordination and problem-solving skills

Priority given to candidates with:

• clinical hospital experience + TPA/insurance exposure + cashless and claims knowledge + audit and documentation experience.