Regional Manager @ T & M Services

Rs.50,000/-Thane

Job Description

1 Managing Claims processes and various operations in the claims department

2. Attending and Managing Central claims committee meetings- scheduling, preparation of Agenda, Minutes of meeting, co-coordinating and communicating all necessary information among members of the committee, maintenance of all important documents and necessary information related to CCC meetings.

3. Making compliance report for AG AUDIT paras.

4. Making compliance report for every phase renewal year.

5. Giving interdepartmental data as per the queries(grievance dept, impalement dept etc).

6. Monitoring various activities of TPAs related to claims and preauthorization's for appropriate
Intervention with information to senior officials.
7. Taking experts opinion from the concerned specialist regarding particular procedures, investigation, guidelines and the cost of the packages
8. Replying to RTI's (Right to information), LAQ's (Legislative assembly Question) and Letters from Higher government bodies like DHS, PHD, Govt. & Pvt. Empanelled hospitals.
9. Preparing/ Verifying Claims analysis reports like performance of MJPJAY (in terms of no. of Preauths, surgery/therapy and claims), Claims turnaround time (TAT) report, Claims status report etc.
10. Providing data of MJPJAY to other Govt. departments ( PHD, NCD, Govt. Hospital) as per there requirement.
11. Coordinating between network hospitals (Private & government.) and Third Party Administrators (TPAs) during claims processing and Preauth, and resolving their queries.
12. Coordinating with interdepartmental staff, Regional Managers, District Coordinators, ADCs and MCOs for various works related to claims department
13. Coordinate with patients and/or relatives of patient whenever necessary for both Mahatma Jyotiba Phule Janarogya Yojana and PMJAY.
14. Handling grievances of Patients and Network Hospitals across the state.
15. Communicating with NIC (Insurer) for compliance of various activities.
16. Attending queries by walk in hospital MCO's or doctors.
17. Solving queries related to health care and medical.
18. Performing all duties as assigned by superiors.
19. Attending and review of TPA performance with data analysis and queries regarding particular
Preauth and claim cases in TPA meeting.
20. Receiving district and hospital wise claims issues from all DC's during DC meetings and resolving the same
21. Review of present adjudication guidelines, procedure list and mandatory investigations checklist and working for the necessary changes and revision and updating of current guidelines
22. Visiting and communicating with different specialist doctor from Government or Private hospital for new proposed procedure under MJPJAY, cost of procedures and regarding mandatory investigation checklist for preauth and claims.
23. Revision of RFP, procedure list, adjudication guidelines and mandatory investigation checklist for the launch of new integrated scheme of PMJAY & MJPJAY
24. Processing claims of PMJAY (trust mode cases) and National TMS (for patients from Maharashtra taking treatment in other states)
25. Attending training sessions related to PMJAY