Pre-auth Clinical Consultant

3Sixty Health has a great opportunity for a suitably qualified individual to fulfil the advertised position and join their team.

**3SIXTY HEALTH **3Sixty Health is a black owned and managed, reputable and a major player in driving South African economy by investing in ‘’black excellence’’3Sixty Health is 100% black owned and black managed administrator. It is
**BACKGROUND **accredited by the council for medical schemes to offer both administration and managed care services, allowing for a fully integrated, beneficiary-centric approach. Our core competencies in administration include membership management, billing, claim adjudication and customer services.

It is a medical aid administrator of Sizwe Hosmed Medical Scheme.

**POSITION **Pre-Auth Clinical Consultant

**DIVISION **Managed Health Care

**DEPARTMENT **Hospital Utilization

**JOB PURPOSE**

**LOCATION **Head Office (Johannesburg)

**DUTIES AND RESPONSIBILITIES**
- Validation of membership and benefits availability according to Pre-authorisation policies and procedures
- Authorisation of procedures and admission to hospital based on medical necessity
- Contact relevant suppliers regarding acceptance or denial of authorisation within 24 hours prior to admission
- Source appropriate information to resolve issues
- Record all authorisations and queries handled
- Prepare cases for review by the medical advisor
- Identify and document patients with chronic conditions
- Fostering relationships with staff at assigned hospitals to improve coordination of care at appropriate levels;
- Handling of queries effectively and efficiently.
- Ensure proposed clinical procedures and length of stay are appropriate
- Provide patients with pre-operation instructions
- Adhere to Call Centre standards of above 97% calls answered
- Meet call Centre daily targets according to company service level agreements
- Adhere to workflow standard according to policies and procedures
- Oversee the intercompany transactions - lead internal intercompany confirmations on a quarterly basis
- Attendance of finance meetings in order to provide insights and strategic analysis on the financial health of the

Group

**QUALIFICATIONS**
- Matric
- Registered/ enrolled nurse ( with SANC) with 3 years relevant nursing experience in the Medical Aid sector
- Computer Literate
- Proficiency and fluency in English and another official language
- Excellent Telephone Manner
- Good communication and interpersonal skills with customer focus.
- Previous Pre-authorisations experience would be advantageous
- Sound knowledge of Prescribed Minimum Benefits
- Sound knowledge of National Reference Price list remove
- Basic knowledge of ICD 10 and CPT coding

**CORE COMPETENCIES**
- Ability to work under pressure and as part of a Team
- Willingness to work overtime when necessary
- Enthusiasm to accept and develop in a changing environment
- Attention to detail and accuracy
- Professional
- Able to take responsibility and use own initiative
- Assertive
- Goal-orientated

**Job Type**: Permanent

Ability to commute/relocate:

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

Application Question(s):

- Are you a Registered/ enrolled nurse?

Do you have Basic knowledge of ICD 10 and CPT coding?
Do you have a Sound knowledge of Prescribed Minimum Benefits?

**Education**:

- High School (matric) (required)

**Experience**:

- relevant nursing: 3 years (required)

Application Deadline: 2023/05/02