Clinical Authorization Specialist

24 hours ago


Cape Town, Western Cape, South Africa Palesa Mbali Group Full time
Job Title: Prospective Reviewer

At Palesa Mbali Group, we are seeking a highly skilled and experienced Prospective Reviewer to join our Pre-Authorization Call Centre team.

Key Responsibilities:
  • Authorize hospital authorization requests by applying coding principles, medical scheme rules, and benefits, and managed care policies and processes.
  • Capture accurate pre-authorisation data on the system.
  • Educate and assist members by providing relevant clinical information to access the correct clinical benefits.
  • Consult members' healthcare professionals to make informed clinical decisions and manage financial risk.
  • Correctly escalate complex clinical calls.
  • Provide excellent customer service.
  • Address all customer complaints in alignment with policies and procedures to achieve stakeholder buy-in.
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 Us:

Palesa Mbali Group is a highly respected company with many of the top medical schemes under our umbrella. We are committed to providing excellent service to our members and are seeking a talented individual to join our team.



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