Clinical Pre-Authorisation Consultant (Registered - Pretoria
Join our team in Pretoria as we collaborate with our valued client to seek a Clinical Pre-Authorisation Consultant (Registered Nurse). We are looking for an ideal candidate who holds a registered nurse qualification, backed by a degree or diploma and is registered with the South African Nursing Council (SANC). Additionally, the candidate should bring a minimum of two years of experience in Managed Healthcare or Private Hospital settings to the table. Responsibilities: Application Review: You'll be responsible for receiving and processing applications that necessitate pre-authorization.Telephonic Authorizations: Handle pre-authorizations for hospital and radiology services via our call center.Data Entry and Verification: Accurately capture and validate clinical information, including ICD-10 and item codes.Membership Confirmation: Verify membership status and available benefits before granting authorization.Special Requests: Evaluate and process special pre-authorization requests.Code Accuracy: Ensure the correct coding is applied before approving benefits.Clinical Analysis: Provide clinical interpretation and analysis of medical reports and doctor's motivations.Information Dissemination: Offer clear and applicable information regarding scheme rules, benefits, and approvals to patients and service providers.Benefits Approval: Accurately approve benefits based on benefit options and protocols to minimize the scheme's risk.Data Management: Thoroughly and accurately record all relevant information and approved documents in our operational systems.High-Quality Service: Deliver exceptional service to members and service providers.Stay Informed: Keep up-to-date with changes in scheme rules, benefit options, legislation, protocols, processes, and systems. Skills and Qualifications: Education: A minimum of a Grade 12 certificate.Nursing Qualification: Must hold a registered nurse degree/diploma and be registered with SANC.Relevant Experience: Two years of experience in a private hospital setting.Legislative Knowledge: Comprehensive understanding of the Medical Schemes Act.Coding Proficiency: Sound knowledge of CPT-4 and ICD-10 codes, with RPL proficiency.Skills Set: Possess technical and professional knowledge and skills, strong work management abilities, customer focus, excellent verbal and written English communication skills, and proficiency in understanding spoken and written Afrikaa https://protool.gumtree.co.za/external-link-browser.html?urlaHR0cHM6Ly93d3cuZGl0dG8uam9icy9qb2IvZ3VtdHJlZS8xOTMwNjY1MTA/c291cmNlPWd1bXRyZWU&jid1725026&xid193066510
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