Pre-authorisation Consultant

2 weeks ago


Pretoria, South Africa HRInsync Full time

**Pre-Authorisation Consultant**

**Introduction**

One of the largest private Medical Aid companies in SA. They have been providing healthcare to the lives of South Africans for over 56 years. And are striving to be #1 in SA.

**Purpose**

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

**Duties & Responsibilities**
- Client Relations, to assist the client by approving appropriate funding
- Effective Customer Service delivery, to deliver an effective call centre service in order to achieve member satisfaction
- Telephone Etiquette, answering telephone calls in a way that achieves member satisfaction
- Verifying prosthesis limits, to contain costs for both members and fund
- On-going training and development, to update knowledge and skills in order to deliver a cost-effective and professional service
- The actual benefit expenditure per beneficiary per month for hospitalization should be less than the budget benefit expenditure
- Pre-authorization should be granted within the option benefits, Scheme and clinical protocols
- Delivering a cost-effective Managed Healthcare service within the average length of hospital stay per beneficiary
- Thorough, well-grounded clinical knowledge of Pre-Authorization of hospital admissions and Case Management of hospital cases in order to take cost-effective and appropriate decisions in evaluating treatment, LOS and LOC
- Knowledge of the current coding structures in the South African Health Care environment i.e. ICD10’s, CPT4, NRPL, and PMB conditions, protocols and Scheme rules

**Skills & Qualifications**

Qualification - Essential
- Grade 12
- Enrolled Nurse

Qualification - Preferred
- B Cur degree / Diploma in Nursing
- Registered Nurse

Experience - Essential
- Minimum 5 years’ experience as a nursing practitioner
- Minimum 1-year experience gained in the medical funding industry

Ability to commute/relocate:

- Pretoria, Gauteng: Reliably commute or planning to relocate before starting work (required)

**Education**:

- Diploma (required)

**Experience**:

- nursing: 5 years (required)
- medical aid schemes: 1 year (required)


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