Head TPA & Claims Process Controller & Audits - Corporate Office

Job Description

Designation: Head – TPA & Claims Process Controller & Audits Location: Thane Corporate Office Department: TPA & Claims Qualification: BAMS / BHMS / MBBS with Post-Graduation in Healthcare Management Professional Experience: 5+ years of experience in a tertiary care hospital or the health insurance sector Main Objective of the Role To ensure compliance in complete end-to-end claim processing, disbursement, and settlement for all insurance and corporate patients. Key Responsibilities 1. Medical Claims Compliance & Processing Oversight Ensure 100% compliance in claims processing through the IHX portal. Monitor the 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 accordance with the agreed MoUs with partners and corporates. Monitor and control disallowances and short payments post final approvals. Supervise the claim settlement process within the HMIS system. Liaise, engage, and coordinate with insurance companies and TPA partners. 2. 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. 3. Process Improvement & Compliance Develop and implement efficient claims processing procedures and controls. Monitor and analyze claims trends and processing metrics for improvement opportunities. 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 adjudication criteria. 4. Training & Clinical Support Provide clinical expertise for complex medical cases and claims handling. Conduct training for claims processors on medical terminology, coding, and best practices. Stay updated with medical, coding, and regulatory developments to ensure ongoing process improvements. MIS Reports Claim Intake Summary Report Claims Under Process Query & Dispute Log Claims Workflow Tracker Aging Analysis Report Short Payment & Disallowance Summary Claims Settlement Dashboard TPA/Insurer Performance Report Compliance Scorecard Financial Impact Report High-Value Claims Review Clinical Coding Accuracy Report Supplementary Position Guidelines Key Relationships: External: TPAs, Insurance Companies, Corporate Clients Internal: Billing Team, Claim Processing Team, Finance Team Note: Interested candidates can email their resume at Jobs@jupiterhospital.com Show more Show less