Key Responsibilities:
● Insurance Eligibility Check
- Understanding of Health Insurance terminologies Such as Sum insured, Balance Sum
insured , Room eligibility, Capping/Sublimit , Coverage , NME
- Explore corporate based insurance eligibility
● Pre-Auth Document Validation and Adjudication:
- Validate and adjudicate pre-authorization documents.
- Ensure all necessary documents are shared with the hospital and that pre-authorization
is raised and followed up on effectively.
● Approval and Communication:
- Update the internal tool once approval is received from the hospital.
- Provide financial counseling to patients as needed, in coordination with the CB
(Customer/Billing).
● Hospital Alignment:
- Ensure proper alignment with hospitals to avoid miscommunication.
- Confirm that the hospital conducts financial counseling, obtains patient consent, and
shares the signed copy with the MB Financial Operations team.
● Query Resolution:
- Ensure timely resolution of queries for all cases.
● Pre-Auth and Claim Rejections:
- Share a list of all pre-auth rejection cases with the IS TLs for cash and EMI counseling.
- For claim rejection cases, persuade patients to opt for cash (first preference) or EMI
options, and explain these options to both the CB and the patient, if required.
● Discharge Process
- Carefully review discharge documents before sharing them with the TPA to ensure room
eligibility, tariff accuracy, and genuine billing.
- Address TPA queries promptly and provide clear justifications to minimize repeated or
multiple queries.
- Ensure that hospitals collect out-of-pocket (OOP) payments as per the discharge
approval to avoid excess payments.
● Monitoring and Communication:
- Monitor WhatsApp groups and emails for any concerns raised by hospitals and the
Inside Sales Team.
- Assist Inside Sales in document collection and sharing, ensuring cases are properly
raised in Lead Square.
Basic Requirements:
Medical Background: Understanding of medical terminology and procedures.
Experience in Hospital Billing and Insurance: Familiarity with hospital billing processes
and insurance claims.
TPA Insurance SPOC: Experience as a single point of contact for TPA insurance
processes.
Preferred Qualifications:
- Strong communication and interpersonal skills.
- Ability to work collaboratively with hospitals, patients, and internal teams.
- Proficiency in using financial and healthcare management tools.
- Attention to detail and problem-solving skills.
- This JD outlines the responsibilities and qualifications for a Senior Associate role
focused on -pre-authorization and cashless processes in financial operations. Adjust the
details as needed to fit your organization's specific requirements.