Job Description

Position: Clinical Consultant (Pre-authorisations)
Department: Member Care
Remuneration: Competitive market-related CTC package, including medical aid and provident fund
Working Hours: 8 hour Rotational shifts between 07h00 and 19h00 (Monday to Sunday) - Time off in lieu of weekend worked (enquire for further detail)
Pretoria based Managed Care Organisation specialising in integrated clinical management services to low-income medical schemes seeks to employ a Clinical Pre-Authorisation Consultant to their team.
Minimum Qualifications:

• Registered or Enrolled Nurse (Diploma/ Degree)
• Current SANC Registration is essential

Required Skills & Competencies:

• 2-3 years of Pre-authorisation experience within a managed healthcare or medical scheme setting
• Exceptional verbal and written communication skills, particularly in a call centre environment (assessment will be conducted)
• Proficient in computer systems (assessment will be conducted); experience with MIP and/or MedCaps applications is beneficial
• Strong customer service orientation with the ability to engage effectively with external stakeholders, including healthcare providers and scheme members
• Capacity to manage high-pressure situations with professionalism and empathy
• Self-driven and capable of working independently
• Excellent organisational and prioritisation abilities
• Multitasking proficiency
• Fluent in English (written and spoken); an additional language would be advantageous
• Strong analytical and research skills
• High level of accuracy and attention to detail
• Ability to compile and submit reports within strict deadlines
• Results-driven approach
• Commitment to maintaining confidentiality
• Strong understanding of the South African healthcare sector, industry regulations, and medical coding structures (ICD-10, CPT-4, NRPL, PMB conditions, and clinical protocols) Testing on procedure codes will be conducted
• Solid clinical expertise in pre-authorising hospital admissions, including length of stay, level of care, in-room procedures, and other healthcare services requiring prior approval

Key Responsibilities:

• Handle inbound calls from healthcare providers and medical scheme members regarding pre-authorisations
• Verify benefit eligibility according to scheme rules, clinical protocols, and funding guidelines
• Process authorisations and apply standard protocols within a telephonic interaction
• Ensure strict compliance with scheme benefits, rules, and clinical guidelines for all service authorisations
• Perform clinical risk assessments to mitigate risks associated with hospital admissions and other pre-authorised healthcare services
• Identify any co-morbid conditions and escalate cases to case management for further intervention if necessary
• Respond to general inquiries related to benefits and authorisations
• Present complex cases to case management for further assessment and resolution
• Educate members on healthcare processes and guide those with chronic conditions into active disease management programs

Ready to take on this exciting challenge?
Please apply to response@mvgrecruitment.co.za, REF: MVG/PAuthPret.
Supporting Documents Required:

• Copy of Comprehensive CV detailing Pre-Auth experience
• Copy of SANC Registration
• Copy of Nursing Diploma
• Copy of Matric Certificate