TPA Assistant Manager

Carelan Healthcare; Gurugram District; On-site; INR 350,000 - 550,000; Full time

Job summary

Carelan Healthcare in India is seeking a dedicated Insurance Claims Coordinator to decode health policies, verify eligibility and manage pre-authorisation and final claim settlements. You will coordinate with hospitals, TPAs and patients to gather documents, track cases from admission to final approval, and ensure accurate documentation to maximise eligible claim value.

Strong knowledge of surgical procedures, medical terminology and surgical billing is required.

Responsibilities

• Decode and interpret corporate and personal health insurance policies.
• Check patient eligibility, coverage, exclusions, deductibles, co-pay and policy limits.
• Prepare and file pre-authorisation requests with TPAs/insurance companies.
• Coordinate with hospitals and insurance desks for required medical documents.
• Follow up and obtain initial/pre-authorisation approval.
• Prepare and submit documents for final approval/claim settlement.
• Handle queries, objections, deductions and clarification requests raised by TPAs/insurers.
• Strongly present and justify the medical necessity and admissibility of the case.
• Ensure maximum eligible claim value is captured as per policy terms and supporting documentation.
• Coordinate with hospitals, doctors, patients and insurance/TPA teams throughout the case.
• Track cases from admission/pre-auth through discharge and final approval.
• Maintain proper documentation and case records.
• Identify opportunities to reduce unnecessary deductions and improve claim realisation.
• Have good knowledge of surgical procedures, medical terminology and surgical billing.

Job description

• Decode and interpret corporate and personal health insurance policies.
• Check patient eligibility, coverage, exclusions, deductibles, co-pay and policy limits.
• Prepare and file pre-authorisation requests with TPAs/insurance companies.
• Coordinate with hospitals and insurance desks for required medical documents.
• Follow up and obtain initial/pre-authorisation approval.
• Prepare and submit documents for final approval/claim settlement.
• Handle queries, objections, deductions and clarification requests raised by TPAs/insurers.
• Strongly present and justify the medical necessity and admissibility of the case.
• Ensure maximum eligible claim value is captured as per policy terms and supporting documentation.
• Coordinate with hospitals, doctors, patients and insurance/TPA teams throughout the case.
• Track cases from admission/pre-auth through discharge and final approval.
• Maintain proper documentation and case records.
• Identify opportunities to reduce unnecessary deductions and improve claim realisation.
• Have good knowledge of surgical procedures, medical terminology and surgical billing.Role & responsibilities