Clinical Pre Authorization Consultant
2 days ago
Handling of telephonic authorisations, hospital and radiology on the pre-authorisation call centre.
- Capture clinical information and verify the information, including the applicable ICD-10 and item codes.
- Confirm membership status & available benefits on the system before authorisation can be granted.
- Validate and evaluate special pre-authorisation requests.
- Ensure that the correct codes are used before benefits are approved.
- Clinical interpretation and analysis of medical reports and/or doctor’s motivation.
- Provide correct applicable information in respect of scheme rules, benefits & approvals in respect of all services requiring to patients and service providers.
- Approve benefits accurately according to the benefits per benefit option and strictly according to the protocols to reduce the Scheme’s risk in respect of benefits.
- Accurate and complete capturing of all relevant information as well as approved documents on the appropriate operational systems.
- Deliver a high quality service to the members and service providers.
- Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems.
- Grade 12.
- A completed degree/diploma as a Registered nurse and must be registered with SANC.
- Two year’s relevant experience in a private hospital.
- Comprehensive knowledge of the Medical Schemes Act.
- Sound knowledge of CPT-4 & ICD-10 codes RPL.
- Must possess the following skills:
- Technical and professional knowledge and skills;
- Managing work;
- Customer focus;
- Good verbal and written English communication skills as well as proficiency in understanding Afrikaans spoken and written communication;
- Computer literate.
- Must work well with people and be able to handle conflict situations.
- Must be willing to be multiskilling in other sections within managed care.
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