Consultant Nurse Pretoria - Pretoria
Qetello Holdings
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. 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 the 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. 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 Afrikaans communication. Computer literacy is essential. Interpersonal Skills: Ability to work effectively with people and handle conflict situations. Adaptability: Willingness to cross-train in other sections within managed care. Market-Related
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