Clinical Benefits Agent

2 weeks ago

Nelspruit, South Africa Mediplus SA Full time

The Clinical Benefits Agent is responsible for managing pre-authorizations and overseeing case management to ensure optimal patient care and efficient resource utilization. This role involves facilitating communication between members, client relations, and healthcare providers, negotiating tariffs, managing risks, and coordinating air evacuations when necessary.

**Key Responsibilities**:

- **Pre-Authorizations**: Evaluate, process, and communicate medical pre-authorization decisions.
- **Case Management**: Monitor and manage patient cases, coordinate care plans, and ensure efficient resource use.
- **Communication**: Act as a liaison among members, healthcare providers, and client relations, addressing inquiries and resolving issues.
- **Negotiation of Tariffs**: Negotiate cost-effective healthcare tariffs, ensuring compliance with policies and regulations.
- **Risk Management**: Identify and mitigate risks associated with patient care and authorization processes.
- **Compliance**: Handle sensitive personal/medical information securely, adhering to Mediplus SA’s policies and the POPI Act.

**Minimum Requirements**:

- Matric with Mathematics.
- Diploma in business, risk management, or clinical nursing (advantageous).
- Knowledge of anatomy, physiology, ICD10, and procedure codes (strongly advantageous).
- Experience in case management, pre-authorizations, or similar roles (preferred).
- Strong negotiation, communication, and analytical skills.
- Proficiency in Microsoft Office Suite and case management software.

**Competencies**:

- Excellent interpersonal skills and attention to detail.
- Reliable, professional, and able to work collaboratively within a diverse team.
- Knowledge of COID, medical aid rules, and managed healthcare policies.

**What We Offer**:

- A collaborative work environment.
- Opportunities for professional growth.
- Competitive compensation and benefits.

Take the next step in your career and become a vital part of Mediplus SA's mission to deliver exceptional service to our members

**Join Mediplus SA and make a meaningful difference in healthcare**

**Job Type**: Permanent

Pay: R7 700,00 - R9 000,00 per month

Ability to commute/relocate:

- Nelspruit, Mpumalanga: Reliably commute or planning to relocate before starting work (preferred)

**Education**:

- High School (matric) (preferred)

**Experience**:

- Case management: 1 year (preferred)
- Pre-authorization: 1 year (preferred)

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