TPA Executive

JOB DESCRIPTION – TPA EXECUTIVE

Company: Miracle Group of Companies
Department: HR
Designation: TPA Executive

1. Job Purpose

To manage employee medical insurance services, coordinate with Third Party Administrators (TPAs) and insurance companies, facilitate cashless and reimbursement claims, and ensure timely resolution of employee queries related to Group Mediclaim Insurance (GMC).

2. Key Roles & Responsibilities

A. Group Mediclaim Insurance (GMC) Management

• Coordinate the enrollment of new employees and deletion of separated employees under the GMC policy.
• Maintain updated employee insurance records, including policy details, coverage, dependents and e-cards.
• Coordinate with insurance companies and TPAs for policy updates, endorsements and employee coverage-related issues.
• Assist employees in understanding policy benefits, coverage limits, exclusions and claim procedures.

B. Medical Claim Management

• Facilitate cashless hospitalization requests and reimbursement claims.
• Coordinate with TPAs, hospitals and insurance companies for claim documentation and approvals.
• Track pending, approved, rejected and settled claims and follow up for timely resolution.
• Assist employees in resolving claim rejections, deductions and documentation discrepancies.
• Maintain a record of claim status and communicate updates to employees.

C. Employee Coordination & Support

• Act as the primary point of contact for employees regarding GMC and medical insurance queries.
• Guide employees through claim submission, hospitalization procedures and required documentation.
• Maintain professional relationships with employees, TPAs, insurance companies and hospital representatives.
• Ensure employee concerns are addressed promptly and escalated whenever required.
• Conduct awareness sessions to educate employees about insurance benefits and claim procedures.

D. Documentation & Reporting

• Maintain employee-wise insurance records, claim trackers and policy-related documents.
• Prepare periodic reports on claim status, pending cases, claim settlements and employee queries.
• Maintain confidentiality of employee medical information and insurance documents.
• Support policy renewal activities, premium-related data verification and insurance reconciliation.
• Submit regular updates to HR management on unresolved claims and service issues.

E. Vendor & Insurance Coordination

• Maintain effective coordination with insurance brokers, TPAs and insurance providers.
• Follow up on service requests, claim escalations and policy-related discrepancies.
• Monitor service quality and turnaround time for claim processing.
• Support HR during annual GMC renewal, policy comparisons and employee coverage reviews.

3. Key Performance Indicators (KPIs)

• Timely resolution of employee insurance queries.
• Turnaround time for claim follow-ups and escalations.
• Accuracy of employee enrollment, deletion and policy records.
• Percentage of pending claims followed up within the defined timeline.
• Timely issuance and distribution of insurance e-cards.
• Employee satisfaction with insurance support services.
• Timely submission of insurance reports and documentation.
• Effective coordination with TPAs and insurance providers.

4. Educational Qualification

• Graduate in any discipline; preference for Healthcare Administration, Insurance, Commerce or Business Administration.
• Relevant certification in health insurance or claims management will be an advantage.

5. Experience

• 1–3 years of experience in TPA operations, health insurance, GMC administration or medical claim processing preferred.
• Experience in corporate employee mediclaim handling will be an added advantage.

6. Required Skills

• Strong communication and interpersonal skills.
• Knowledge of GMC policies, cashless hospitalization and reimbursement procedures.
• Good follow-up, coordination and problem-solving abilities.
• Proficiency in MS Excel, email and documentation.
• Ability to handle employee concerns with empathy and professionalism.
• Strong attention to detail and confidentiality.

7. Desired Competencies

• Employee-centric approach.
• Ownership and accountability.
• Timely execution and follow-up.
• Accuracy in documentation.
• Professional vendor relationship management.

Pay: ₹10,000.00 - ₹33,000.00 per month

Benefits:

• Cell phone reimbursement
• Provident Fund

Work Location: In person