Pre-auth Agent

7 months ago

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

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A growing Company situated in Benoni is looking for a Pre-Auth Agent who will facilitate the process of pre-authorization as requested by members or service providers in a timely, effective, efficient, equitable and client centred manner.

**Key Performance Areas**
- Pre-Auth Process
- General

**Key Tasks**

**Pre-auth process**
- Bi-daily checks and continuous record keeping ensuring all unanswered PCM and phone calls are phoned back within SLA.
- Prioritize incoming authorization requests and/or queries according to urgency.
- Provide correct applicable information in respect of policy terms and conditions, benefits and preferred providers/ facilities in respect of all services requiring to patients or service providers.
- Assess and authorise or decline pre-authorisation requests for GP, specialist and casualty visits and unplanned accident or medical emergencies based on benefits and policy rules.
- Escalate all pre-authorisation requests for diagnostic and hospitalisation benefits to a Pre-Auth Nurse, Case Manger or Pre-auth Supervisor to sign off on the final outcome.
- Assist with follow-up on outstanding information regarding requests applicable to pre-authorisation for GP visits, specialist visits, emergency room visits, diagnostic procedures, hospitalisation for illness and accident events, including the appropriate facilities (Day clinics, Sub-Acute facilities, home nursing and preferred providers)
- Direct members to preferred/network providers and assist with obtaining information from providers.
- Confirm membership status & available benefits on the system and request applicable documentation (e.g. quotes, cession forms, billing history, motivational letter or accident report).
- Escalate possible non-disclosure of pre-existing conditions to the Pre-Auth Nurses and Underwriting Department.
- To check the reasons for authorisation and documentation received are appropriate and confirm if it is according to set protocols, guidelines, formularies and preferred provider agreements. Based on protocols approve or decline. If the reason for authorisation is not defined in the protocols or guidelines escalate the case for clinical review.
- Approve or decline benefits accurately according to the benefits per benefit option and strictly according to the protocols
- 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
- Process upfront payment request according to protocol and indicate the payment date based on admission date to determine the urgency of the payment
- Appropriate referral to pre-auth agents, case management team

**General**
- Adhere to all verbal or written instructions and comply with Company policies and Regulator requirements
- Accurate and complete capturing of all relevant information as well as approved documents on the appropriate operational systems
- Utilise the SRM system to obtain all documents before sending to clients to ensure latest updated documents is used
- Comply with LMS training deadlines and pass rates
- Maintain confidentiality and do security checks before information is disclosed to clients
- Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems
- Adhere and maintain set turnaround times:

- Answering Calls Within 10 seconds
- Responding to a WhatsApp Within 15 minutes
- Responding to a Please Call Me Within 15 minutes
- Providing an Auth (GP, Specialist, Admission) Within 20 minutes
- Providing a Repudiation Letter Within 24 hours - in writing
- Providing Repudiation feedback Verbally
- within 20 minutes after the outcome is confirmed
- Responding to Escalations Within 1hour
- Responding to Abandoned Calls To be contacted within 1 hour of being sent out
- Feedback on Authorisation request Within 24hours
- Feedback on Case Management Within 8 hours

**Other requirements**
- Able to work shifts

**When the job will be performed**- Day/ night shifts as scheduled

**Essential Qualifications**
- Matric
- Experience in health and customer care industry

**Essential Experience**
- Clinical Experience
- Healthcare industry experience
- Computer Aided Dispatch System
- Managed Healthcare experience

**Knowledge and Skills**
- Administration Skills
- Exceptional Communication Skills.
- Organizing and Time-management skills
- Computer literacy.
- Medical and emergency care terminology.
- Problem solving skills:

- Ability to find solutions to uncommon problems.

**Attributes**
- Compassionate
- Calm
- Professional
- Strong attention to detail
- **H**onest, **H**ardworking and **H**umble

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