Pre-authorisation Nurse

A Medical Insurance Company based in Benoni is looking for a Pre-Authorisation Nurse who will assess the authenticity and legitimacy of requests for medical services or treatment by members or service providers in a timely, effective, efficient, equitable and client centred manner.

**Key Performance Areas**
- Authorise or Decline Medical Services or Treatment
- Mitigate Waste or Abuse of Benefits
- Undertake General Administrative Duties

**Key Tasks**

**Authorise or Decline Medical Services or Treatment**
- Validate membership status and available benefits based on plan type
- Confirm compliance with policy terms and condition, waiting periods and exclusions
- Approve or decline benefits strictly according to the benefits applicable per benefit option and protocols
- Conduct official security checks before information is disclosed to clients
- Refer authorisation or declination to relevant case management team

**Mitigate Waste or Abuse of Benefits**
- Assess pre-authorisation requests for GP visits, specialist visits, emergency room visits, diagnostic procedures and hospitalisation for illness and accident events
- Request applicable documentation (e.g. medical history, motivational letter or accident report) before a final assessment to approve or decline can be made
- Assess continuation of benefits and applicable cover limits
- Exclude possible non-disclosure of pre-existing conditions
- Check that the reasons provided for authorisation and documentation received are appropriate and are according to set protocols, guidelines, formularies and preferred provider agreements.
- Assess pre-authorisation requests for appropriate alternative facilities (i.e., Day clinics, Sub-Acute facilities, Home Nursing and preferred providers)
- Utilise cost effective network providers and appropriate alternative facilities
- Escalate the case for a clinical review if the reason for authorisation is not defined in the protocols or guidelines
- Provide correct information in respect of preferred providers or alternative facilities in respect of all services required by patients or service providers.
- Provide correct information in respect of policy terms and conditions and benefits
- Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems

**Undertake General Administrative Duties**
- Prioritize incoming authorization requests and/or queries according to urgency.
- Process upfront payment request according to protocol
- Determine the urgency of the upfront payment as indicated by comparing the payment and admission dates
- Capture all relevant information, as well as approved documents, on the appropriate operational systems
- Provide members and applicable provider(s) with verbal and/or written notification with regards to the outcome of the pre-authorisation request.
- Handle and escalate appeals on decline authorisation requests and complaints to the clinical review team
- Utilise the Intranet system to obtain all latest updated documents before sending to clients
- Maintain confidentiality and conduct relevant security checks before information is disclosed to clients
- Adhere to all verbal or written instructions and comply with Company policies and Regulator requirements
- Maintain strict compliance with Company policies and Regulator's requirements
- Comply with training and coaching deadlines and QA pass rates

**When the job will be performed**
- 12 hours, Rotational Shifts - Day and Night
- 07h00 to 19h00 and 19h00 to 07h0

**Essential Qualifications**
- Matric
- Diploma or Degree in Nursing as a Registered Nurse

**Desirable Qualifications**
- ICD 10 coding course and/or
- BHF coding course, and/or
- CPT coding course

**Legal or Statutory Requirements**
- Registered with SANC

**Desirable Experience**
- Managed Health Care in a Contact Centre environment
- Theatre and/or ICU experience

**Knowledge and Skills**
- Computer literate
- Demonstrable Administration skills
- Working knowledge of ICD, BHF and CPT Codes

**Attributes**
- Professional
- Flexible
- Detail oriented
- Responsible & Accountable
- **H**onest, **H**ardworking and **H**umble
- For more information please contact:
**Angelique Hart