Pre authorization Case manager at M&M Consulting

M&M Consulting Services and Talent Acquisition; Roodepoort; On-site; ZAR 30 000 - 70 000; Full time

Job summary

An established industry player is seeking a dedicated Registered Nurse to join their dynamic team. In this pivotal role, you will be responsible for pre-authorizing hospital admissions, managing cases, and liaising with healthcare professionals. Your expertise will ensure that members receive the best care possible while adhering to protocols and guidelines. With a focus on cost containment and efficient communication, you will play a crucial role in enhancing patient experiences. If you have a passion for healthcare and a commitment to excellence, this opportunity is perfect for you!

Qualifications

• Registered Nurse with knowledge of the Medical Schemes Act.
• 2 to 5 years of experience, preferably as a Social Worker.

Responsibilities

• Pre-authorize member's admission to hospital as per scheme protocol.
• Manage high care and general ward cases up to R70 000.

Skills

Knowledge of the Medical Schemes Act

Registered Nurse qualification

Education

Diploma

Job description

Job Responsibilities

1. Pre-authorize member's admission to hospital as per scheme protocol and guidelines.
2. Capture authorization on IMED system.
3. Liaise with medical advisor.
4. Handle hospital updates telephonically and via emails.
5. Manage cases through telephonic and email communication, including referral of cases for specialized case management as per guidelines.
6. Monitor ongoing hospital cases and provide final updates, including negotiating discounts.
7. Handle member queries regarding hospitalization and benefits.
8. Manage written communications and motivation reports, including correspondence.
9. Manage cost containment for hospital incidents and admissions.
10. Ensure maintenance of call center SLA.
11. Liaise with hospitals, doctors, members, and family members.
12. Collaborate with other healthcare personnel within the organization.
13. Provide clinical expertise within the organization.

Key Responsibilities

1. Pre-authorize member admissions to hospital according to scheme benefits and departmental protocols and guidelines.
2. Manage high care and general ward cases up to a value of R70 000.
3. Handle telephonic case management of surgical cases up to R80 000 and medical cases up to R60 000, excluding joint replacements.

Qualifications and Skills

Registered Nurse

Desired Skills:

• Knowledge of the Medical Schemes Act
• Registered Nurse qualification

Desired Work Experience:

• 2 to 5 years of experience, preferably as a Social Worker

Desired Qualification Level:

• Diploma