Prospective Reviewer (Preauthorisation Consultant)

Prospective Reviewer (Pre-Authorization Call Centre) The Prospective Reviewer role within the pre-authorization call centre, is responsible for authorizing hospital authorization requests ensuring that requirements of clinical appropriateness, medical necessity and clinical risk management are met.
Key Activities:Authorizing 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 systemEducate and assist member by providing relevant clinical information to access the correct clinical benefitsConsult member's health care professional to make informed clinical decisions and manage financial riskCorrectly escalate complex clinical callProvide excellent customer serviceAddress all customer complaints in alignment with policies and procedures to achieve stakeholder buy-inEducation and Experience:Formal nursing qualification (SANC enrolled nurse) – required2 – 3 years' experience in a general medical or general surgical ward, with at least 1 year at a private institutionMinimum of 3 years in the clinical space requiredMust be computer literateCall centre experience advantageousPrevious Managed Healthcare experience in a call centre environment – advantageousCompany Description:A highly respected company with many of the top medical schemes under their umbrella