Job Description

Our client is seeking a Clinical Pre-Authorisation Consultant to join their dynamic team. If you're a healthcare professional registered with the South African Nursing Council (SANC) as a Registered Nurse or Enrolled Nurse, with at least two years of experience in Managed Healthcare or Private Hospital settings, we encourage you to apply!Key Responsibilities:

• Application Review: Process and evaluate pre-authorisation applications.
• Telephonic Authorisations: Handle pre-authorisations for hospital and radiology services through the call center.
• Data Entry & Verification: Accurately capture and verify clinical details, including ICD-10 and item codes.
• Membership Validation: Confirm membership status and available benefits prior to granting authorisation.
• Special Requests: Assess and process special pre-authorisation applications.
• Coding Accuracy: Apply appropriate coding before approving benefits.
• Clinical Interpretation: Analyse medical reports and doctors' motivations.
• Information Sharing: Provide patients and service providers with clear, relevant information on scheme rules, benefits, and approvals.
• Benefits Management: Approve benefits in line with benefit options and protocols to mitigate scheme risks.
• Record Keeping: Maintain accurate records of all transactions and documentation.
• Service Excellence: Deliver outstanding service to members and providers.
• Continuous Learning: Stay updated on scheme rules, benefit options, legislation, protocols, and system changes.

• Education: Minimum Grade 12 certificate.
• Nursing Qualification: Degree or diploma in nursing; registered with SANC.
• Experience: At least two years in a private hospital or managed healthcare setting.

• Medical Schemes Act.
• Proficiency in CPT-4 and ICD-10 coding, with RPL knowledge.

• Strong technical and professional capabilities.
• Exceptional time and work management.
• Outstanding customer focus.
• Fluent in English (spoken and written) with understanding of Afrikaans.
• Proficient computer literacy.
• Interpersonal Abilities:
• Effective team collaboration.
• Conflict resolution skills.
• Flexibility: Willingness to cross-train in other managed care sections.

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