Clinical Pre-Authorisation Consultant

Our client is seeking a Clinical Pre-Authorisation Consultant to join their dynamic team.

If you're a healthcare professional registered with the South African Nursing Council (SANC) as a Registered Nurse, with at least two years of experience in Managed Healthcare or Private Hospital settings, we encourage you to apply!

Key Responsibilities:

1. Application Review: Process and evaluate pre-authorisation applications.
2. Telephonic Authorisations: Handle pre-authorisations for hospital and radiology services through the call center.
3. Data Entry & Verification: Accurately capture and verify clinical details, including ICD-10 and item codes.
4. Membership Validation: Confirm membership status and available benefits prior to granting authorisation.
5. Special Requests: Assess and process special pre-authorisation applications.
6. Coding Accuracy: Apply appropriate coding before approving benefits.
7. Clinical Interpretation: Analyse medical reports and doctors' motivations.
8. Information Sharing: Provide patients and service providers with clear, relevant information on scheme rules, benefits, and approvals.
9. Benefits Management: Approve benefits in line with benefit options and protocols to mitigate scheme risks.
10. Record Keeping: Maintain accurate records of all transactions and documentation.
11. Service Excellence: Deliver outstanding service to members and providers.
12. Continuous Learning: Stay updated on scheme rules, benefit options, legislation, protocols, and system changes.

Requirements:

1. Education: Minimum Grade 12 certificate.
2. Nursing Qualification: Degree or diploma in nursing; registered with SANC.
3. Experience: At least two years in a private hospital or managed healthcare setting.
4. Knowledge: Medical Schemes Act.
5. Proficiency: CPT-4 and ICD-10 coding, with RPL knowledge.
6. Skills: Strong technical and professional capabilities. Exceptional time and work management. Outstanding customer focus. Fluent in English (spoken and written) with understanding of Afrikaans. Proficient computer literacy.
7. Interpersonal Abilities: Effective team collaboration. Conflict resolution skills.
8. Flexibility: Willingness to cross-train in other managed care sections.

How to Apply:

Interested candidates who meet the requirements are invited to submit their CV and supporting documents to with the subject line "REF : Pre-Auth".

Please note: If you have not received feedback within two weeks of your application, consider your application unsuccessful.