Prospective Reviewer

4 weeks ago


Johannesburg, South Africa Palesa Mbali Group Full time

The Prospective Reviewer role within the pre-authorisation call centre, is responsible for authorising hospital authorisation requests ensuring that requirements of clinical appropriateness, medical necessity and clinical risk management are met.

 

Key Activities:

  • Authorising 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 member by providing relevant clinical information to access the correct clinical benefits
  • Consult member's health care professional to make informed clinical decisions and manage financial risk
  • Correctly escalate complex clinical call
  • Provide excellent customer service
  • Address all customer complaints in alignment with policies and procedures to achieve stakeholder buy-in

 

Education and Experience:

  • 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
  • Trauma/ER experience will be an advantage.
  • Previous Managed Healthcare experience in a call centre environment – advantageous

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