Pre - Authorization Agent

Private Health Administrators (Pty) Ltd; Centurion; On-site; ZAR 250,000 - 360,000; Full time

Job summary

Private Health Administrators (Pty) Ltd seeks a qualified nurse to issue accurate pre-authorisations, ensuring clinical appropriateness and risk management. A formal nursing qualification with SANC registration or equivalent healthcare credential is mandatory, with 2–3 years in managed healthcare preferred.

The role involves data capture, call centre interactions, and applying scheme rules to authorise hospital requests.

Qualifications

• Formal nursing qualification with registration/enrolment with SANC or equivalent healthcare qualification (mandatory).
• Minimum 2–3 years’ experience in Managed Healthcare is advantageous.
• Knowledge of health risk solutions and clinical intervention principles will be beneficial.

Responsibilities

• Advise on best practice health risk solutions to relevant parties.
• Apply clinical intervention principles in daily decisions.
• Capture accurate pre-authorisation data in the system.
• Authorise hospital authorisation requests per scheme rules and policies.
• Escalate complex clinical calls when needed.
• Collaborate with team to meet delivery targets and overall department objectives.

Skills

Emails / HIP / Excel / Word

Negotiation

Telephone Skills

Communication Skills

Business Writing

Systems knowledge

Negotiation & Influence

Problem Solving

Numerical Ability

Customer Focus

Attention to Detail

Education

Nursing qualification with SANC registration or healthcare professional qualification

Job description

Position Purpose: To ensure the accurate issuing of appropriate pre-authorisations that meets the requirements of clinical appropriateness, medical necessity and clinical risk management.

Experience: A minimum of 2-3 years’ experience in Managed Healthcare will be advantageous.

Qualifications: A formal nursing qualification and registration/enrolment with SANC or a formal healthcare professional qualification (Registered / Enrolled Nurse). (MANDATORY REQUIREMENT)

KEY PERFORMANCE AREAS

• Advise on best practice health risk solutions to relevant parties
• Application of clinical intervention principles
• Excellent understanding of Call Centre technology
• Application of financial and risk assessment methodology
• Authorise hospital authorisation requests by applying coding principles, scheme rules and benefits, and managed care policies and processes
• Capture accurate pre-authorisation data on the system
• Correctly escalate complex clinical call
• Meet delivery objectives through working with other team members within and linked to the department / project
• Resolve operational performance variations and problems and elevate unresolved issues to higher levels
• Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery

KEY COMPETENCIES

Knowledge

• Knowledge and application of dispensing of meds, surgical material & procedures
• Application of financial and risk assessment methodology
• Knowledge of scheme rules and contractual negotiations
• Application of clinical intervention principles
• Advise on best practice health risk solutions to relevant parties
• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedure

Skills

• Emails / HIP / Excel / Word
• Negotiation and Telephone Skills
• Communication Skills
• Business Writing Skills
• Relevant systems knowledge and application
• Ability to negotiate and influence
• Problem Solving
• Numerical Ability
• Customer Focus
• Attention to Accuracy and Detail

Note: Company reserves the right to close the advert before specified closing date.

PHA has its head office in Westville, KwaZulu-Natal. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits.