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.Requirements:• 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.Knowledge:• Medical Schemes Act.• Proficiency in CPT-4 and ICD-10 coding, with RPL knowledge.Skills:• 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.How to Apply: