Clinical Authorisation Specialist

1 week ago


Johannesburg, Gauteng, South Africa Palesa Mbali Group Full time
Job Title: Prospective Reviewer

The Prospective Reviewer role within the pre-authorisation call centre is a critical position that requires a high level of clinical expertise and analytical skills. As a Prospective Reviewer, you will be responsible for ensuring that hospital authorisation requests meet the requirements of clinical appropriateness, medical necessity, and clinical risk management.

Key Responsibilities:
  • Authorise hospital authorisation requests by applying coding principles, medical scheme rules, and benefits, as well as managed care policies and processes.
  • Capture accurate pre-authorisation data on the system.
  • Educate and assist members by providing relevant clinical information to access the correct clinical benefits.
  • Consult members' healthcare professionals to make informed clinical decisions and manage financial risk.
  • Correctly escalate complex clinical calls.
  • Provide excellent customer service.
  • Address all customer complaints in alignment with policies and procedures to achieve stakeholder buy-in.
Requirements:
  • Formal nursing qualification (SANC enrolled nurse) – required.
  • 2 – 3 years' experience in a general medical or general surgical ward, with at least 1 year at a private institution.
  • Trauma/ER experience will be an advantage.
  • Previous Managed Healthcare experience in a call centre environment – advantageous.


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