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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 team. The successful candidate will possess a completed qualification as an Enrolled Nurse and must be registered with SANC, along with a minimum of 2 years of experience in Managed Healthcare.

Key Responsibilities:

  • Process applications for all services requiring pre-authorization and manage the requests efficiently.
  • 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 summary of the member's clinical history for review by the medical advisor.
  • Oversee the exchange of documents between the pre-authorization department and the medical advisor.
  • Authorize benefits accurately in accordance with the benefit options and strictly follow established protocols.
  • Identify and escalate potential risks concerning specific members or providers to senior staff.

Qualifications and Skills:

  • Completed Grade 12 education.
  • Registered Enrolled Nurse with SANC.
  • Minimum of 2 years' experience in Managed Healthcare.
  • Proficient in verbal and written English communication, with the ability to understand Afrikaans.
  • Computer proficiency in Microsoft Office.
  • Strong customer service orientation.
  • Able to work collaboratively in a team and manage conflict effectively.
  • Knowledge of the following:
    • Thorough understanding of the Medical Scheme Act;
    • Solid knowledge of CPT-4, ICD-10, and RPL codes;
    • Extensive clinical expertise;
    • Ability to work independently with sound decision-making capabilities;
    • Demonstrated strong work ethic.

Only candidates meeting the outlined qualifications will be considered for this position. We appreciate your understanding that only those selected for further consideration will be contacted.