Pre-authorisation Nurse

4 months ago

Johannesburg, South Africa Talent Pal Full time

A Medical Insurance Company based in Benoni is looking for a Pre-Authorisation Nurse who will assess the authenticity and legitimacy of requests for medical services or treatment by members or service providers in a timely, effective, efficient, equitable and client centred manner.

**Key Performance Areas**
- Authorise or Decline Medical Services or Treatment
- Mitigate Waste or Abuse of Benefits
- Undertake General Administrative Duties

**Key Tasks**

**Authorise or Decline Medical Services or Treatment**
- Validate membership status and available benefits based on plan type
- Confirm compliance with policy terms and condition, waiting periods and exclusions
- Approve or decline benefits strictly according to the benefits applicable per benefit option and protocols
- Conduct official security checks before information is disclosed to clients
- Refer authorisation or declination to relevant case management team

**Mitigate Waste or Abuse of Benefits**
- Assess pre-authorisation requests for GP visits, specialist visits, emergency room visits, diagnostic procedures and hospitalisation for illness and accident events
- Request applicable documentation (e.g. medical history, motivational letter or accident report) before a final assessment to approve or decline can be made
- Assess continuation of benefits and applicable cover limits
- Exclude possible non-disclosure of pre-existing conditions
- Check that the reasons provided for authorisation and documentation received are appropriate and are according to set protocols, guidelines, formularies and preferred provider agreements.
- Assess pre-authorisation requests for appropriate alternative facilities (i.e., Day clinics, Sub-Acute facilities, Home Nursing and preferred providers)
- Utilise cost effective network providers and appropriate alternative facilities
- Escalate the case for a clinical review if the reason for authorisation is not defined in the protocols or guidelines
- Provide correct information in respect of preferred providers or alternative facilities in respect of all services required by patients or service providers.
- Provide correct information in respect of policy terms and conditions and benefits
- Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems

**Undertake General Administrative Duties**
- Prioritize incoming authorization requests and/or queries according to urgency.
- Process upfront payment request according to protocol
- Determine the urgency of the upfront payment as indicated by comparing the payment and admission dates
- Capture all relevant information, as well as approved documents, on the appropriate operational systems
- Provide members and applicable provider(s) with verbal and/or written notification with regards to the outcome of the pre-authorisation request.
- Handle and escalate appeals on decline authorisation requests and complaints to the clinical review team
- Utilise the Intranet system to obtain all latest updated documents before sending to clients
- Maintain confidentiality and conduct relevant security checks before information is disclosed to clients
- Adhere to all verbal or written instructions and comply with Company policies and Regulator requirements
- Maintain strict compliance with Company policies and Regulator's requirements
- Comply with training and coaching deadlines and QA pass rates

**When the job will be performed**
- 12 hours, Rotational Shifts - Day and Night
- 07h00 to 19h00 and 19h00 to 07h0

**Essential Qualifications**
- Matric
- Diploma or Degree in Nursing as a Registered Nurse

**Desirable Qualifications**
- ICD 10 coding course and/or
- BHF coding course, and/or
- CPT coding course

**Legal or Statutory Requirements**
- Registered with SANC

**Desirable Experience**
- Managed Health Care in a Contact Centre environment
- Theatre and/or ICU experience

**Knowledge and Skills**
- Computer literate
- Demonstrable Administration skills
- Working knowledge of ICD, BHF and CPT Codes

**Attributes**
- Professional
- Flexible
- Detail oriented
- Responsible & Accountable
- **H**onest, **H**ardworking and **H**umble
- For more information please contact:
**Angelique Hart

  • Pre - Authorisation

    4 months ago

    Johannesburg, South Africa Edge Executive Search Full time

    Our client based in the North is looking for an analytical and attention-to-detail Consultant within their Pre - Authorisation department. Key Requirements: Possess a nursing qualification and Emergency Services qualification or any other Clinical/Medical qualification 3-5 years of Pre-Auth experience is required Previous exposure to Renal Dialysis,...

  • Prospective Reviewer

    4 months ago

    Johannesburg, South Africa Palesa Mbali Group Full time

    The Prospective Reviewer role within the pre-authorisation call centre, is responsible for authorising hospital authorisation requests ensuring that requirements of clinical appropriateness, medical necessity and clinical risk management are met. Key Activities:Authorising hospital authorization requests by applying coding principles, medical scheme rules...

  • Junior Pre-authorisation Consultant

    1 week ago

    Johannesburg, Gauteng, South Africa Dymaxa Recruitment Full time

    Dymaxa Recruitment is seeking a skilled professional to fill the role of Junior Pre-authorisation Consultant. The ideal candidate will possess excellent analytical thinking skills, be assertive, and demonstrate caring and confident behaviour. They will also be perceptive and professional in their approach, with a strong ability to work independently and as...

  • Clinical Authorisation Specialist

    7 days ago

    Johannesburg, Gauteng, South Africa Palesa Mbali Group Full time

    Job Title: Prospective ReviewerThe Prospective Reviewer role within the pre-authorisation call centre is a critical position that ensures the efficient processing of hospital authorisation requests. This role requires a strong understanding of clinical appropriateness, medical necessity, and clinical risk management principles.Key Responsibilities:Authorise...

  • Pre-auth Agent

    3 months ago

    Johannesburg, South Africa National Risk Managers (Pty) Ltd Full time

    Join Our Exclusive Talent Pool! We believe in nurturing talent and providing a platform for growth. As we expand our horizons, we are building a talent pool of passionate professionals who share our commitment to excellence. A growing Company situated in Benoni is looking for a Pre-Auth Agent who will facilitate the process of pre-authorization as requested...

  • Junior Pre-authorisation Consultant

    2 weeks ago

    Johannesburg, South Africa Dymaxa Recruitment Full time

    Our client, a non-profit, medical scheme is seeking a Junior Pre-Auth Consultant HBM for the Pretoria area.Behavioural CompetencyAnalytical thinkingAssertiveCaring and ConfidentEmotional maturityFlexibleHonest approachPerceptive and professional behaviourSelf-motivated and Open-mindedDuties include but not limited to:Delivering of cost-effective managed...

  • Registered Nurse

    3 months ago

    Johannesburg, South Africa National Risk Managers (Pty) Ltd Full time

    A Medical Insurance Company based in Benoni is looking for a Registered Nurse who will consult with members via relevant platforms to diagnosis and provide treatment plans for members according to Primary Healthcare Guidelines. Ensuring best clinical practice and quality is always provided to members. Handling of calls within Service level agreements. **Key...

  • Registered Nurse

    4 months ago

    Johannesburg, South Africa National Risk Managers (Pty) Ltd Full time

    A Medical Insurance Company based in Benoni is looking for a Registered Nurse who will consult with members via relevant platforms to diagnosis and provide treatment plans for members according to Primary Healthcare Guidelines. Ensuring best clinical practice and quality is always provided to members. Handling of calls within Service level agreements. **Key...

  • Registered Nurse

    3 months ago

    Johannesburg, South Africa National Risk Managers (Pty) Ltd Full time

    A Medical Insurance Company in Benoni is looking for a Registered Nurse - General. The Registered Nurse - General will Consult Health members via relevant platforms to diagnosis and provide treatment plans for members according to Primary Healthcare Guidelines and handling of calls within Service level agreements **Job Summary** - Consult with Affinity...

  • Nursing Professional

    1 week ago

    Johannesburg, Gauteng, South Africa Intercare Full time

    About IntercareAt Intercare, we're dedicated to delivering value-based healthcare to our patients. Our purpose is to make people feel better, and our shared values of People-centred, Integrity, Inclusivity, Excellence, and Innovation guide everything we do.Job OpportunityWe're seeking an Enrolled Nurse to join our team at Intercare Northriding Medical and...

  • Registered Nurse

    4 weeks ago

    Johannesburg, South Africa Intercare Group South Africa Full time

    **ABOUT** Intercare is a dynamic healthcare company focusing on offering value-based healthcare to patients. As ambassadors of the Intercare brand, everything we do is guided by our purpose to make people feel better. Our shared values of People-centred, Integrity, Inclusivity, Compassion, Excellence and Innovation define what we believe and who we...

  • Registered Nurse Icu Trained

    5 months ago

    Johannesburg, South Africa LetsLink Pty Ltd Full time

    LetsLink recruitment is currently seeking a Registered Nurse with ICU training to join the team of a private hospital in Gauteng. As a ICU Trained Registered Nurse, you will be responsible for providing direct and/or indirect nursing care to patients, assessing patient needs, and executing nursing care plans. You will be expected to participate in Clinical...

  • Registered Nurse Icu Trained

    5 months ago

    Johannesburg, South Africa LetsLink Pty Ltd Full time

    LetsLink recruitment is currently seeking a Registered Nurse with ICU training to join the team of a private hospital in Johannesburg. As a ICU Trained Registered Nurse, you will be responsible for providing direct and/or indirect nursing care to patients, assessing patient needs, and executing nursing care plans. You will be expected to participate in...

  • Enrolled Nurse

    3 months ago

    Johannesburg, South Africa Intercare Full time

    ABOUT Intercare is a dynamic healthcare company focusing on offering value-based healthcare to patients. As ambassadors of the Intercare brand, everything we do is guided by our purpose to make people feel better. Our shared values of People-centred, Integrity, Inclusivity, Excellence and Innovation define what we believe and who we are. A great...

  • Professional Nurse

    4 months ago

    Johannesburg, South Africa Anova Health Institute NPC Full time

    Anova is an NGO that empowers people and changes lives. Good health and quality of life is what motivates us to provide healthcare solutions and support for those who need it most. _ - We are looking for a Professional Nurse to_ provide direct service delivery and health system strengthening through initiating or enhancing the roll-out various services...

  • Professional Nurse Talent

    4 months ago

    Johannesburg, South Africa Anova Health Institute NPC Full time

    Anova is an NGO that empowers people and changes lives. Good health and quality of life is what motivates us to provide healthcare solutions and support for those who need it most. The Business is looking to build a ready now talent pool for Professional Nurse who are ready, assessed to fill vacancies when opportunities arise. We are looking for a...

  • Surgical Nurse Gauteng, Fourways Area

    4 months ago

    Johannesburg, South Africa Optivet Full time

    Assisting in surgical procedures alongside the specialists Monitoring and ensuring the well-being of surgical patients Providing pre - and post-operative care with finesse Collaborating closely with the entire surgical team Contributing to the enhancement of our surgical protocols Dip/Degree in Veterinary Nursing SAVC Registration Updated CPD...

  • Enrolled Nurse

    3 weeks ago

    Johannesburg, Gauteng, South Africa Intercare Full time

    About IntercareIntercare is a dynamic healthcare organization focused on delivering value-based care to patients. As ambassadors of the Intercare brand, our purpose is to make people feel better. Our core values of People-centred, Integrity, Inclusivity, Excellence, and Innovation guide our actions and define who we are.Job SummaryWe are seeking an Enrolled...

  • Research Nurse

    3 weeks ago

    Johannesburg, Gauteng, South Africa AJ Personnel Full time

    Job SummaryWe are seeking a highly skilled and experienced Research Nurse to join our team at AJ Personnel. The successful candidate will be responsible for facilitating and aiding in the recruitment and follow-up of study participants, as well as acting as a patient advocate and assisting in the coordination and management of clinical research studies.Key...

  • Case Manager

    3 months ago

    Johannesburg, South Africa Palesa Mbali Group Full time

    **Key Activities** - Identify treatment trends and patterns to manage clinical and financial risk - Defined legal, statutory, and regulatory compliance is maintained at the required standards - Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary - Ensure...