Manager (TPA -Operations)

Vidal Health Insurance; Bengaluru; On-site; INR 350,000 - 550,000; Full time

Job summary

Vidal Health Insurance seeks a detail-oriented professional to manage health claims processing and governance. You will monitor reimbursement settlements, ensure adherence to insurer SLAs, and establish adjudication guidelines to support accurate and timely claim decisions.

The role requires coordinating with insurers and TPAs, tracking KPI metrics, and producing regular MIS reports to drive operational efficiency and issue resolution.

Qualifications

• Experience in health claims management and governance.
• Ability to analyze data and monitor KPIs.
• Familiarity with insurer guidelines and SLAs.

Responsibilities

• Monitor Network and reimbursement claim settlement.
• Ensure the claims are processed within the agreed TAT as per Insurer SLA
• Establish claim adjudication guidelines and governance frameworks.
• Monitor TPA performance against SLAs as per Metrics.
• Follow up monthly operational reviews with MIS team.
• Coordination with Insurer on daily basis for Rejection and approval claims
• Resolve service issues and escalations from Insurer.
• Ensure compliance with insurer guidelines.
• Preparing reports

Skills

Health claims management

TPA governance

Fraud risk assessment

Data analytics

SLA compliance

TPA quality scores

Operational efficiency

Excel

Claims adjudication

Analytical ability

Tools

Excel

Job description

Key Responsibilities

• Monitor Network and reimbursement claim settlement.
• Ensure the claims are processed within the agreed TAT as per Insurer SLA
• Establish claim adjudication guidelines and governance frameworks.
• Monitor TPA performance against SLAs as per Metrics.
• Follow up monthly operational reviews with MIS team.
• Coordination with Insurer on daily basis for Rejection and approval claims
• Resolve service issues and escalations from Insurer.
• Ensure compliance with insurer guidelines.
• Preparing reports

Key Skills

• Health claims management.
• TPA governance.
• Fraud risk assessment.
• Data analytics.
• SLA compliance.
• TPA quality scores.
• Operational efficiency.
• Excel knowledge
• Claims adjudication
• Analytical ability