Together with our client we are recruiting for a Clinical Pre-Authorisation Consultant (Call Centre) in Pretoria. The Candidate must be a registered nurse with SANC and have at least two years’ experience in the private healthcare sector. Previous experience working at a Medical Aid Scheme would be an advantage.
Duties and Responsibilities
- Receive applications for all services which require pre-authorisation.
- Handling of telephonic authorisations, hospital, radiology and specialist referrals on the pre-authorisation call centre.
- Capture clinical information and verify the information, including the applicable ICD-10 and item codes.
- Confirm membership status & available benefits on the system before authorisation can be granted.
- Validate and evaluate special pre-authorisation requests.
- Ensure that the correct codes are used before benefits are approved.
- Clinical interpretation and analysis of medical reports and/or doctor’s motivation.
- Provide correct applicable information in respect of scheme rules, benefits & approvals in respect of all services requiring to patients and service providers.
- Approve benefits accurately according to the benefits per benefit option and strictly according to the protocols to reduce the Scheme’s risk in respect of benefits.
- Accurate and complete capturing of all relevant information as well as approved documents on the appropriate operational systems.
- Deliver a high-quality service to the members and service providers.
- Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems
- A completed degree/diploma as a registered nurse and must be registered with SANC.
- Two year’s relevant experience in a private hospital.
- Comprehensive knowledge of the Medical Schemes Act.
- Sound knowledge of CPT-4 & ICD-10 codes RPL.
Must possess the following skills:
- Technical and professional knowledge and skills;
- Managing work;
- Customer focus;
- Good verbal and written English communication skills as well as proficiency in understanding Afrikaans spoken and written communication;
- Computer literate.
- Must work well with people, and be able to handle conflict situations
- R 27 000 – R 33 000 Cost to Company (depending on experience)
- Pension Fund
- 13th cheque
- Medical Aid
If you meet the above mentioned requirements please send your CV, Qualifications and SANC registration to firstname.lastname@example.org with REF: Medical Case Manager