Claims Authorisation & Risk Clerk

Mediclinic International; Pretoria; On-site; ZAR 180,000 - 240,000; Full time

Job summary

Mediclinic Muelmed in Arcadia, Pretoria is hiring to minimise financial risk by ensuring authorisation and re-authorisation of all cases through effective communication between relevant parties. You will obtain authorisation, capture data, and identify risk cases while adhering to clinical coding standards.

The role requires Grade 12 or equivalent, experience in a clinical environment, and knowledge of funder contracts, AS400 systems, and relevant Acts.

Qualifications

• Funder contracts and medical aid requirements/narrations.
• Patient admin programmes on the AS400 system.
• Rules and regulations regarding funder contracts.
• Clinical coding (Level 2 coding).
• B2B EMS (electronic message system: check status of authorisations and use for trouble,shooting).
• Relevant aspects of applicable statutory acts (e.g. Consumer Protection Act; PMB; etc.).
• Patient Administration policies and procedures (e.g. Patient Confidentiality; Visitation of external case managers; etc.).
• Daily workflow; managing deviances; coding; and case management processes.
• Identify possible financial risks (e.g. no authorisation; insufficient LOS or LOC; etc.).

Responsibilities

• Obtain authorisation and re-authorisation for all identified patients to ensure fully paid claims.
• Capture data and communicate to all parties.
• Identify and refer risk cases to minimise financial risks.
• Adhere to clinical coding standards as per Level 2 coding guideline.
• Ensure compliance to the confirmation procedure contracts and legal aspects by utilising available resources and systems.

Skills

Funder contracts

Medical aid requirements/narrations

AS400 patient admin

Regulations (funders)

Clinical coding (Level 2)

B2B EMS status checks

Statutory acts awareness

Patient confidentiality

Case management processes

Daily workflow management

Financial risk identification

Education

Grade 12 or equivalent

Tools

AS/400 system

Job description

Mediclinic Muelmed in Arcadia, Pretoria is hiring to minimise financial risk by ensuring authorisation and re-authorisation of all cases through effective communication between relevant parties. You will obtain authorisation, capture data, and identify risk cases while adhering to clinical coding standards.

The role requires Grade 12 or equivalent, experience in a clinical environment, and knowledge of funder contracts, AS400 systems, and relevant Acts.