Senior Officer Pre Authorisation
Pretoria, Gauteng, South Africa
Job Description
About the role:To ensure that applications for pre authorisation justify clinical intervention and are finalized fairly, effectively and in full.
Essential functions of the job:
- Receive applications for all services, which require pre authorisation and attend to the request.
- Capture clinical information and verify the information, including the applicable ICD-10 and items codes.
- Validate and evaluate special pre authorisation requests.
- Prepare a summary of the members clinical history for the medical advisor.
- Monitor the flow of documents between the pre authorisation division and the medical advisor.
- Approve benefits accurately according to the benefits per benefit options and strictly according to protocols.
- Escalate identified risks about specific members or providers to senior.
Grade 12, with a completed qualification as an Enrolled Nurse and must be registered with SANC, with at least 2 years experience in Managed Healthcare.
Skills and knowledge:
Good verbal and written English communication skills as well as proficiency in understanding Afrikaans spoken and written communication.
Computer literate in Ms Office.
Customer focus.
Must be able to work in a team and handle conflict situations.
Knowledge of the following: -
Comprehensive knowledge of the Medical Scheme Act;
Sound knowledge of CPT-4, ICD-10 and RPL codes;
Extensive clinical knowledge;
Able to function independently with good decision making skills; and exceptional work ethic.
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Job Detail
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Job IdJD1266335
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IndustryNot mentioned
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Total Positions1
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Job Type:Full Time
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Salary:Not mentioned
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Employment StatusPermanent
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Job LocationPretoria, Gauteng, South Africa
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EducationNot mentioned