Clinical Authorization Specialist

1 month ago


Pretoria, Gauteng, South Africa Qetello Holdings Full time
Job Overview

In this role, you will work as a Clinical Pre-Authorization Consultant at Qetello Holdings. As a key member of our team, you will be responsible for reviewing pre-authorisation applications and ensuring that they meet the required criteria.

Key Responsibilities
  • Application Review: Process and evaluate pre-authorisation applications to ensure accuracy and compliance with regulations.
  • Telephonic Authorisations: Handle pre-authorisations for hospital and radiology services through telephonic interactions with patients and service providers.
  • Data Entry & Verification: Accurately capture and verify clinical details, including ICD-10 and item codes, to support decision-making.
  • Membership Validation: Confirm membership status and available benefits prior to granting authorisation to ensure seamless service delivery.
  • Special Requests: Assess and process special pre-authorisation applications requiring additional analysis or expertise.
  • Coding Accuracy: Apply appropriate coding before approving benefits to ensure accurate reimbursement.
  • Clinical Interpretation: Analyse medical reports and doctors' motivations to inform decision-making.
  • Information Sharing: Provide patients and service providers with clear, relevant information on scheme rules, benefits, and approvals.
  • Benefits Management: Approve benefits in line with benefit options and protocols to mitigate scheme risks.
  • Record Keeping: Maintain accurate records of all transactions and documentation to ensure transparency and accountability.
  • Service Excellence: Deliver outstanding service to members and providers, focusing on exceptional customer experience.
  • Continuous Learning: Stay updated on scheme rules, benefit options, legislation, protocols, and system changes to maintain expertise and adapt to evolving requirements.
Requirements
  • Education: Minimum Grade 12 certificate, with a degree or diploma in nursing.
  • Nursing Qualification: Registration with the South African Nursing Council (SANC).
  • Experience: At least two years of experience in a private hospital or managed healthcare setting.
Estimated Salary:

R500,000 - R700,000 per annum, depending on qualifications and experience.

About Us

Qetello Holdings is a dynamic organisation dedicated to providing innovative solutions in the healthcare sector. We are committed to delivering exceptional service and fostering a culture of excellence among our team members.



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