HBM PRE-AUTHORISATION CONSULTANT

Bestmed Medical Scheme; Gauteng; On-site; ZAR 420,000 - 540,000; Full time

Benefits offered by this job

23 days annual leave

8-hour workday with 30 min lunch

Life cover, disability, funeral cover,

Medical aid access

Training and development opportunities

On-site gym and wellness programme

Job summary

Bestmed Medical Scheme in Gauteng is seeking a HBM Pre-Authorisation Consultant within the Hospital Benefit Management Department. The role focuses on delivering cost-effective managed healthcare and ensuring member satisfaction through accurate pre-authorisation decisions.

The ideal candidate will have Grade 12, enrolled nursing qualification, and at least 5 years of nursing practice experience in ICU, trauma, theatre, or specialised wards, with active SANC membership.

Qualifications

• Must have Grade 12 and enrolled nursing qualifications.
• Active SANC membership is mandatory.
• Minimum 5 years’ experience as a nursing practitioner in ICU, trauma, theatre or specialised ward.

Responsibilities

• Act as the link between service providers, members and funding rules.
• Evaluate and approve/decline hospital funding requests before procedures.
• Verify member eligibility and coverage under plan type.
• Review limits, apply scheme rules, and manage exclusions and co-pays.
• Validate clinical codes (ICD, CPT, SAMA) and review doctor notes.
• Escalate complex cases and issue authorisation numbers as needed.
• Handle high volume calls and emails; communicate potential shortfalls or exclusions.
• Maintain confidentiality and comply with POPIA and SLAs.

Education

Grade 12

Enrolled Nursing

Active SANC Membership

Job description

Bestmed Gauteng has an opportunity available for a HBM Pre-Authorisation Consultant position in the Hospital Benefit Management Department.

Job purpose: Delivering cost-effective managed healthcare services to accomplish member satisfaction.

The successful candidate should have:

• Grade 12
• Enrolled Nursing
• Minimum 5 years’ experience as a nursing practitioner in ICU, Trauma, Theatre or any other Specialised Ward
• Active SANC Membership

Key responsibilities include:

• Pre-Auth agents act as the vital link between service providers, members and the Scheme`s funding rules.
• Evaluate and approve or decline funding requests for hospital admissions and specialised treatments, before the procedure takes place.
• Need to verify member eligibility, confirm whether the membership is active, and assess benefits to determine whether the requested procedures are covered under the member's plan type.
• Review limits and check available limits. An important role is to apply scheme rules; enforce exclusions, co-payments where needed and confirm DSPs.
• Validate clinical codes, that is, ICD, CPT or SAMA codes.
• Review clinical motivation letters, check doctor notes and pathology against clinical protocols. If needed, escalat complex cases, and issue auth numbers.
• Handle high volume calls, emails, and clearly communicate potential shortfalls, co-payments or exclusions.
• Need to meet Service Level agreements; adhere to strict turnaround times; flag irregular coding or any suspicious requests to Fraud and Waste; maintain confidentiality and comply with POPIA.

Bestmed is a non-profit, mutual, self-administered medical scheme registered with the Council for Medical Schemes. We have been providing healthcare to the lives of South Africans for over 60 years. We are the largest self-administered scheme and the fourth largest open medical scheme in South Africa.

Bestmed offers an exceptional benefit programme and competitive packages, including:

• 23 days annual leave
• A workday of only 8 hours, including a 30 minute lunch break.
• Permanent employees have the options under our corporate umbrella fund, which includes life cover, disability benefits, funeral cover and pension fund.
• Permanent employees also have access to medical aid.
• Access to training and development opportunities are plentiful.
• Office benefits include, free Wi-Fi, an on-site gym, and a wellness programme.

We are committed to ensuring that all employees have opportunities for professional development, as well as fair compensation and employee benefits. We are also committed to ensuring a pleasant and mutual work environment, where innovation is welcomed and encouraged. As such, we reinforce a culture of zero tolerance towards any forms of inappropriate behaviour, abuse (including abuse of power, privilege or trust), harassment, or exploitation of any kind to safeguard our members, employees and partners. All employees are required to share in this commitment through our Code of Conduct.

Bestmed is an equal opportunity, disability-confident employer and we are committed to achieving the highest standards of diversity, fairness and equality. We conduct the most appropriate pre-employment assessments and verification checks to ensure that high standards are maintained.

Bestmed reserves the right to schedule and cancel assessments and interviews. Bestmed also reserves the right not to make a placement.

If you are willing to lead the way, go the extra mile, do the right thing, be upbeat and play for the team…you may be the perfect candidate to join a journey that is Personally Yours with Bestmed!