Pre-auth Agent

5 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 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

For more infor

  • Funeral Field Sales Agent

    2 months ago

    Johannesburg, South Africa Moladira Skills Full time

    The Funeral Sales Agent is responsible for generating leads, promoting funeral service packages, and providing compassionate and professional assistance to families in need of funeral and burial arrangements. The agent will educate potential clients on pre-need and at-need funeral services, assist with insurance claims, and maintain relationships to ensure...

  • Funeral Field Sales Agent

    2 months ago

    Johannesburg, South Africa Moladira Skills Full time

    The Funeral Sales Agent is responsible for generating leads, promoting funeral service packages, and providing compassionate and professional assistance to families in need of funeral and burial arrangements. The agent will educate potential clients on pre-need and at-need funeral services, assist with insurance claims, and maintain relationships to ensure...

  • Debt Collection Agent Constantia Kloof

    6 months ago

    Johannesburg, South Africa Affirmative Portfolios Full time

    Debt Collection Agent - Constantia Kloof Sales / Marketing / Communications JHB West, Johannesburg - Gauteng SARS Debt Collection Agent R4 400p/m + Comm Constantia Kloof Purpose This company is appointed to the panel of the South African Revenue Services as its third-party debt collection and revenue recovery agent. This means that the company has to...

  • Debt Collection Agent

    5 months ago

    Johannesburg, South Africa Affirmative Portfolios Full time

    **Sales / Marketing / Communications** **JHB West, Johannesburg - Gauteng** ***: **SARS Debt Collection Agent - R4 400p/m + Comm** **Constantia Kloof** **Purpose** This company is appointed to the panel of the South African Revenue Services as its third-party debt collection and revenue recovery agent. This means that the company has to source new,...

  • Debt Collection Agent

    6 months ago

    Johannesburg, South Africa Affirmative Portfolios Full time

    **Call Centre** **JHB West** ***: **SARS Debt Collection Agent - R4 400p/m + Comm** **Constantia Kloof** **Purpose** This company is appointed to the panel of the South African Revenue Services as its third-party debt collection and revenue recovery agent. This means that the company has to source new, qualified and experienced debt collection agents for...

  • Property Rental Agent

    5 months ago

    Johannesburg, South Africa IGrow Wealth Investments Full time

    IGrow Wealth Investments, South Africa’s #1 Property Investment Company, is looking for a **Rental Agent **to join their team in Gauteng. Our fast-paced environment creates tremendous opportunities for dynamic people who want to earn a basic salary with a lucrative commission structure. IGrow Rentals is uniquely positioned in that you are not required to...

  • Financial Outbound Agent

    5 months ago

    Johannesburg, South Africa Job Crystal Full time

    A dynamic, innovative and inspiring company providing fintech solutions across multiple sectors is looking for Concierge Sales Agents. This multi-functional role provides an excellent opportunity for an experienced individual with Outbound sales, E-commerce and Superior Customer Service experience. **DUTIES AND RESPONSIBILITIES** - To meet the set standards...

  • Unlock Your Earning Potential as a Sales Agent

    3 days ago

    Johannesburg, Gauteng, South Africa UDM International Ltd Full time

    Company OverviewUDM International Ltd is a leading sales company that has successfully worked with top industry players like Alexander Forbes and Metropolitan Life. Our 17-year partnership with Platinum Life has enabled us to become experts in selling long-term insurance and skincare products.Salary and BenefitsOur average monthly income is R25,500.00, plus...

  • Become a TOP sales agent

    2 weeks ago

    Johannesburg, South Africa UDM International Ltd Full time

    Interested in building a career at UDM International and taking this once in a lifetime opportunity? Become a sales agent - fully paid training provided UDM International has worked successfully with leading industry companies such as Alexander Forbes and Metropolitan Life, winning the Top Sales Campaign award along the way. For the past 17 years we've been...

  • Letting Agent

    5 months ago

    Johannesburg, South Africa Ithemba Property Management Pty Ltd Full time

    Responsibilities include but are not limited to: - To receive pre-qualified leads, initiate contact with leads to understand their needs and preferences. - To provide potential clients with cost breakdown and visuals about possible fit to their requirements. - To coordinate viewings for prospective tenants in a professional and engaging manner, addressing...

  • Transit Shed Agent

    6 months ago

    Johannesburg, South Africa DHL Full time

    **IT’S NOT JUST AN OPPORTUNITY TO GET ON THE CAREER LADDER.** **IT’S AN OPPORTUNITY TO HELP THE WORLD GET ON TOGETHER** - Why do people call us the world’s most international company? Is it because we operate in more countries than any other logistics provider? Is it because we invented cross border shipping over 45 years ago? Or is it, perhaps,...

  • Global Import Logistics Coordinator

    1 day ago

    Johannesburg, Gauteng, South Africa BLACK TIE RECRUIT Full time

    We are seeking a highly skilled Import Logistics Coordinator to enhance our service levels and streamline our import processes.The ideal candidate will have excellent communication skills, be able to work effectively in a team environment, and possess strong problem-solving abilities.This role involves liaising with airlines, ground handling agents, and...

  • Funeral Service Representative

    4 weeks ago

    Johannesburg, Gauteng, South Africa Moladira Skills Full time

    Funeral Sales Agent RoleAt Moladira Skills, we're seeking a Funeral Sales Agent to join our team. As a Funeral Sales Agent, you will be responsible for promoting funeral service packages and providing compassionate assistance to families in need of funeral and burial arrangements.Key Responsibilities:Identify and engage potential clients for funeral services...

  • Africa Manager

    5 months ago

    Johannesburg, South Africa Kontak Recruitment SA Full time

    Johannesburg, Gauteng - Transportation/Logistics **Africa Manager - International Logistics (JB4337)** **Johannesburg, Gauteng** **Market Related** **Duration: Permanent** The Africa Manager plays a pivotal role in overseeing the performance and relationships with agents across Africa, while also mitigating risks associated with shipping, customs, and...

  • Funeral Service Representative

    1 month ago

    Johannesburg, Gauteng, South Africa Moladira Skills Full time

    Funeral Field Sales AgentMoladira Skills is seeking a skilled Funeral Field Sales Agent to join our team. As a Funeral Field Sales Agent, you will be responsible for generating leads, promoting funeral service packages, and providing compassionate and professional assistance to families in need of funeral and burial arrangements.Key Responsibilities:Identify...

  • IT Support Agent

    2 months ago

    Johannesburg, South Africa Capital Recruit Full time

    Job Description The Tele-Maintenance Coordinator plays a vital role in ensuring the seamless operation of the WiFi company's products and services. This position is responsible for providing expert online product support to both technicians and customers, addressing challenges related to in-field routers and the free wifi content platform. The...

  • Unlock Your Sales Potential as a UDM International Representative

    1 week ago

    Johannesburg, Gauteng, South Africa UDM International Ltd Full time

    About UDM International">At UDM International, we have established ourselves as a trusted partner to leading industry companies. Our success is evident in the Top Sales Campaign award we won, and our 17-year exclusive partnership with Platinum Life speaks volumes about our commitment to excellence.">A Career Opportunity like No Other">We are currently...

  • Clearing and Customs administrator

    4 months ago

    Johannesburg, South Africa Curiska Full time

    Basic duties include, but are not limited to:-• Forecasting of Purchase orders on pre-approved orders placed in advanced.• Create and send out all accurate purchase orders.• Processing of GRV’s once stock is received.• Ensure goods received are checked and loaded promptly onto the system.• Notify Sales of stock received.• Calculation of landed...

  • Business Process Manager

    8 months ago

    Johannesburg, South Africa MSA Outsourcing Solutions (Pty) Ltd Full time

    **Primary Function - KPI Management and Maintenance** ▪ Identify lack of KPI’s on all campaigns and start the implementation process by exploring the expectations of the client and documenting them. ▪ Once expectations are discovered and documented, the document should be sent to the client for approval. ▪ The agent(s) must be made aware of the...

  • Clearing and Customs administrator

    4 months ago

    Johannesburg, South Africa Curiska (Pty) Ltd Full time

    Basic duties include, but are not limited to:-• Forecasting of Purchase orders on pre-approved orders placed in advanced.• Create and send out all accurate purchase orders.• Processing of GRV’s once stock is received.• Ensure goods received are checked and loaded promptly onto the system.• Notify Sales of stock received.• Calculation of landed...