Healthcare Pre-Authorization Specialist

2 months ago

Pretoria, Gauteng, South Africa Qetello Holdings Full time

Qetello Holdings is seeking a qualified Medical Pre-Authorization Consultant to join our dynamic team. The successful candidate will possess a completed qualification as an Enrolled Nurse and must be registered with SANC, alongside a minimum of 2 years of experience in the Managed Healthcare sector.

Key Responsibilities:

  • Process applications for services requiring pre-authorization and manage the requests effectively.
  • Document clinical details and confirm the accuracy of the information, including relevant ICD-10 and item codes.
  • Assess and validate special pre-authorization requests.
  • Compile a comprehensive summary of the member's clinical history for review by the medical advisor.
  • Oversee the documentation flow between the pre-authorization department and the medical advisor.
  • Authorize benefits accurately in accordance with the benefit options and established protocols.
  • Identify and escalate any risks associated with specific members or providers to senior staff.

Qualifications and Skills:

  • Matriculation certificate (Grade 12).
  • Completed qualification as an Enrolled Nurse.
  • Current registration with SANC.
  • A minimum of 2 years' experience in Managed Healthcare.
  • Strong verbal and written communication skills in English, with the ability to understand Afrikaans.
  • Proficient in Microsoft Office applications.
  • Customer-oriented approach.
  • Able to work collaboratively in a team and manage conflict effectively.
  • Knowledgeable in the following areas:
    • Thorough understanding of the Medical Scheme Act;
    • Familiarity with CPT-4, ICD-10, and RPL codes;
    • Extensive clinical knowledge;
    • Ability to work independently with sound decision-making skills;
    • Demonstrates a strong work ethic.

Only candidates who meet the outlined qualifications will be considered for this position. We appreciate your interest in Qetello Holdings.

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