Managed Care Consultant

3 days ago


Pretoria, Gauteng, South Africa Ananzi Full time

We are seeking a highly skilled Clinical Pre-Authorisation Consultant to join our team at Ananzi. As a key member of our managed care section, you will play a vital role in ensuring the smooth operation of our services. If you are a motivated and organised individual with a passion for healthcare, we encourage you to apply.

About the Role:
  • We require a Registered Nurse with experience in managed healthcare or private hospital settings, registered with the South African Nursing Council (SANC).
  • This role involves working closely with our managed care team to ensure seamless coordination of services.
Responsibilities:
  1. Application Review: Process and evaluate pre-authorisation applications, making informed decisions based on scheme rules and regulations.
  2. Telephonic Authorisations: Handle pre-authorisations for hospital and radiology services through our call centre, providing exceptional customer service to members and providers.
  3. Data Entry & Verification: Accurately capture and verify clinical details, including ICD-10 and item codes, ensuring accuracy and attention to detail.
  4. Membership Validation: Confirm membership status and available benefits prior to granting authorisation, upholding the highest standards of integrity and professionalism.
  5. Special Requests: Assess and process special pre-authorisation applications, applying knowledge of scheme rules and regulations.
  6. Coding Accuracy: Apply appropriate coding before approving benefits, ensuring compliance with industry standards.
  7. Clinical Interpretation: Analyse medical reports and doctors' motivations, providing clear and concise explanations to members and providers.
  8. Information Sharing: Provide patients and service providers with clear, relevant information on scheme rules, benefits, and approvals, promoting transparency and trust.
  9. Benefits Management: Approve benefits in line with benefit options and protocols to mitigate scheme risks, upholding the highest standards of financial management.
  10. Record Keeping: Maintain accurate records of all transactions and documentation, adhering to industry standards and regulatory requirements.
  11. Service Excellence: Deliver outstanding service to members and providers, ensuring their needs are met and expectations exceeded.
  12. Continuous Learning: Stay updated on scheme rules, benefit options, legislation, protocols, and system changes, remaining current and knowledgeable in the field.


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