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Clinical Pre-Authorisation Expert

2 weeks ago

Pretoria, Gauteng, South Africa Qetello Holdings Full time

Qetello Holdings requires a highly skilled Clinical Pre-Authorisation Expert to join our team. The ideal candidate will have a completed qualification as an Enrolled Nurse and be registered with SANC, with at least 2 years experience in Managed Healthcare.

Job Description
  • The Clinical Pre-Authorisation Expert will receive applications for all services requiring pre-authorisation and attend to the request.
  • Capturing clinical information and verifying it, including ICD-10 and item codes, is crucial to this role.
  • Validating and evaluating special pre-authorisation requests is also key to the position.
  • The expert will prepare a summary of the members' clinical history for the medical advisor.
  • Monitoring the flow of documents between the pre-authorisation division and the medical advisor is also required.
  • The expert will approve benefits accurately according to the benefits per benefit options and strictly according to protocols.
  • Escalating identified risks about specific members or providers to seniors is also required.