Job Description

Claims Processing:

Oversee the end-to-end process of insurance claims submission and follow-up.

Ensure accuracy and completeness of claim documentation before submission.

Coordinate with medical billing and coding teams to resolve claim discrepancies.

Third-Party Administrator (TPA) Management:

Develop and maintain relationships with TPAs to streamline communication and enhance collaboration.

Negotiate and review service agreements with TPAs to ensure favorable terms for the hospital.

Monitor TPA performance and address any issues promptly.

Verification and Authorization:

Verify patient insurance coverage and obtain necessary authorizations for procedures and treatments.

Collaborate with medical staff and insurance companies to address authorization-related issues.

Reimbursement and Revenue Cycle Management:

Monitor and analyze reimbursement trends to identify opportunities for revenue enhancement.

Implement strategies to reduce claim denials and improve reimbursement rates.

Claims Denial Management:

Investigate and analyze reasons for claims denials and implement corrective actions.

Collaborate with the finance team to appeal denied claims and minimize financial impact.

Reporting and Analytics:

Generate regular reports on insurance and TPA performance metrics.

Provide insights and recommendations based on data analysis to improve processes and financial outcomes.

Regulatory Compliance:

Stay informed about changes in healthcare insurance regulations and ensure the hospital's compliance.

Implement and update policies and procedures to align with regulatory requirements.

Customer Service:

Serve as a point of contact for insurance companies, TPAs, and internal stakeholders regarding insurance-related inquiries.

Address patient concerns related to insurance and claims processing.