Prospective Reviewer (Pre-Authorisation Call Centre)

The Prospective Reviewer role within the pre-authorisation call centre is responsible for authorising hospital authorisation requests, ensuring that requirements of clinical appropriateness, medical necessity, and clinical risk management are met.
Key Activities:

Authorising hospital authorization requests by applying coding principles, medical scheme rules and benefits, and managed care policies and processes.
Capture accurate pre-authorisation data on the system.
Educate and assist members by providing relevant clinical information to access the correct clinical benefits.
Consult members' health care professionals to make informed clinical decisions and manage financial risk.
Correctly escalate complex clinical calls.
Provide excellent customer service.
Address all customer complaints in alignment with policies and procedures to achieve stakeholder buy-in.

Education and Experience:

Formal nursing qualification (SANC enrolled nurse) – required.
2 – 3 years' experience in a general medical or general surgical ward, with at least 1 year at a private institution.
Trauma/ER experience will be an advantage.
Previous Managed Healthcare experience in a call centre environment – advantageous.


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