Clinical Pre-Authorisation Consultant

Qetello Holdings; Pretoria; On-site; ZAR 300 000 - 600 000; Full time

Job summary

An established industry player is looking for a Clinical Pre-Authorisation Consultant to enhance their dynamic team. This role is ideal for healthcare professionals registered with the South African Nursing Council, who have a passion for delivering exceptional service in a fast-paced environment. You will be responsible for processing pre-authorisation applications, verifying clinical details, and providing clear information to patients and service providers. If you have a nursing qualification and experience in managed healthcare or private hospitals, this is a fantastic opportunity to contribute to a vital aspect of healthcare management while advancing your career.

Qualifications

• Registered with SANC as a Nurse with 2+ years in Managed Healthcare.
• Proficient in ICD-10 and CPT-4 coding.

Responsibilities

• Process pre-authorisation applications and handle telephonic authorisations.
• Verify clinical details and confirm membership status.

Skills

Technical and Professional Capabilities

Time Management

Interpersonal Abilities

Fluency in English

Understanding of Afrikaans

Flexibility

Education

Nursing Degree or Diploma

Tools

ICD-10 Coding

CPT-4 Coding

Job description

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 or Enrolled Nurse, with at least two years of experience in Managed Healthcare or Private Hospital settings, we encourage you to apply!

Key Responsibilities :

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

Requirements :

• Nursing Qualification : Degree or diploma in nursing; registered with SANC.
• Experience : At least two years in a private hospital or managed healthcare setting.

Knowledge :

• Medical Schemes Act.
• Proficiency in CPT-4 and ICD-10 coding, with RPL knowledge.

Skills :

• Strong technical and professional capabilities.
• Exceptional time and work management.
• Fluent in English (spoken and written) with understanding of Afrikaans.
• Interpersonal Abilities :
• Effective team collaboration.
• Flexibility : Willingness to cross-train in other managed care sections.