Medical Insurance Cashless & Reimbursement Claim Specialist

Experience Required

3 to 5 years (in Hospital / Clinic TPA \& Insurance Desk Operations handling Cashless and Reimbursements)

About the Role

We are looking for an experienced and proactive Senior Executive – TPA \& Medical Insurance Desk to lead our clinic’s insurance assistance services. In this role, you will take complete ownership of end-to-end cashless claim pre-authorizations, patient documentation for reimbursements, and prompt query resolution with major TPAs and insurance companies.

You will act as the crucial link between our patients, clinical staff, and TPA desks to ensure a smooth, transparent, and hassle-free financial experience for every patient.

Key Responsibilities

Cashless Pre-Authorization and Claim Settlement Management

• Obtain and fill out initial TPA pre-authorization forms accurately using doctor case notes and diagnostic findings.
• Submit initial cashless requests, top-up enhancements, and final approval requests on portal tools within strict Turn-Around-Times (TAT).
• Follow up actively with TPA and insurance claim underwriters to minimize pre-authorization holding times.
• Ensure timely cashless claim settlements

Reimbursement Documentation \& Query Resolution

• Guide reimbursement patients step-by-step through claim form requirements, day to day itemized bill generation, discharge/summary documentation, and payment receipts.
• Own end-to-end resolution for patient queries, shortfall letters, and rejections issued by insurance companies.
• Coordinate directly with attending doctors and medical record teams to draft accurate clinical clarification letters for TPA queries.
• Follow up with Patients to know reimbusement status and updating claim tracker

Patient Counseling \& Desk Operations

• Provide clear counseling to patients regarding co-pay conditions, deductible limits, non-payable items, and overall policy coverage.
• Maintain accurate daily records of all active, pending, approved, and disputed claims in the clinic system.
• Maintain relationships with network insurance surveyors, medical officers, and TPA relationship managers in Hyderabad.

Required Skills \& Qualifications

• Experience: 3–5 years of hands-on experience handling TPA portals and insurance desks in a hospital, day-care center, or polyclinic in Hyderabad
• Technical Knowledge: Deep working knowledge of major TPA portals (e.g., Star Health, Medi Assist, FHPL, MDIndia, Vidal Health, Care Health, ICICI Lombard, Niva Bupa).
• Medical Terminology: Ability to comprehend medical diagnosis summaries, ICD/CPT codes, and clinical query letters.
• Languages: Fluency in Telugu, Hindi, and English is mandatory for patient counseling and written communication.

Key Performance Metrics (KPIs)

• Pre-Auth TAT: Submission of pre-authorization requests within 30–45 minutes of medical decision.
• Query Resolution Rate: Resolving clinical/financial TPA query letters within 24 hours.
• Claim Approval Ratio: Maintaining a low initial query/rejection rate through error-free documentation.

Pay

₹45,000.00 - ₹50,000.00 per month

Experience

• Medical Claim (Cashless \& Reimbursement) Processing: 3 years (Required)

Work Location

In person