Clinical Pre Authorization Consultant (Call Centre) positions vacant due to an expansion of the Company's structure. The incumbent is responsible for rendering exceptional service to all members, service providers and brokers.
The job requirements are as follows :
A completed degree / diploma as a registered nurse and must be registered with SANC.
Two year’s relevant experience in a private hospital.
Comprehensive knowledge of the Medical Schemes Act.
Sound knowledge of CPT-4 & ICD-10 codes RPL.
Must possess the following skills :
Provide correct applicable information in respect of scheme rules, benefits & approvals in respect of all services requiring patients and service providers.
Approve benefits accurately according to the benefits per benefit option and strictly according to the protocols to reduce the Scheme’s risk in respect of benefits.
Accurate and complete capturing of all relevant information as well as approved documents on the appropriate operational systems.
Deliver high-quality service to the members and service providers.
Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes, and systems.
Receive applications for all services which require pre-authorization. Handling of telephonic authorizations, hospital, radiology and specialist referrals on the pre-authorization call center.
Capture clinical information and verify the information, including the applicable ICD-10 and item codes.
Confirm membership status & available benefits on the system before authorization can be granted.
Validate and evaluate special pre-authorisation requests.
Ensure that the correct codes are used before benefits are approved.
Clinical interpretation and analysis of medical reports and / or doctor’s motivation.
The selection process includes a practical evaluation where we test general work-related knowledge and computer skills (word and excel).
A few Afrikaans questions will form part of this process but they can reply in English.