Clinical Authorization Specialist

7 days ago


Cape Town, Western Cape, South Africa Palesa Mbali Group Full time

As a Clinical Authorization Specialist at Palesa Mbali Group, you will play a crucial role in ensuring that hospital authorization requests are processed efficiently and effectively. Your primary responsibility will be to review and authorize requests, ensuring that they meet the necessary clinical criteria, medical necessity, and risk management requirements.

Key Responsibilities:

  • Review and authorize hospital authorization requests, applying coding principles, medical scheme rules, and managed care policies and processes.
  • Capture accurate pre-authorization data on the system, ensuring that all relevant information is recorded.
  • Educate and assist members by providing relevant clinical information to access the correct clinical benefits.
  • Consult with members' healthcare professionals to make informed clinical decisions and manage financial risk.
  • Correctly escalate complex clinical calls, ensuring that all necessary steps are taken to resolve the issue.
  • Provide excellent customer service, addressing all customer complaints in alignment with policies and procedures.

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.
  • Minimum of 3 years in the clinical space required.
  • Must be computer literate.
  • Call centre experience advantageous.
  • Previous Managed Healthcare experience in a call centre environment – advantageous.

About Palesa Mbali Group:

Palesa Mbali Group is a highly respected company with many top medical schemes under their umbrella. We are committed to providing excellent service to our members and are seeking a skilled Clinical Authorization Specialist to join our team.



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