Overview
Member Care Clinical Consultant/Pre-authorisations Jobs in Pretoria, South Africa at H2R Africa
Position: Member Care Clinical Consultant (Pre-authorisations)
Ensuring that healthcare services requiring pre-authorization are evaluated and processed
POSITION INFO :
Our client in the Medical Industry, based in Pretoria, has a Permanent vacancy for a Member Care Clinical Consultant (Pre-Autorisation).
Job Purpose :
The role of a Member Care Clinical Consultant (Pre-Authorisations) involves ensuring that healthcare services requiringpre-authorization are evaluated and processed efficiently, aligning with medical necessity and policy guidelines.
Responsibilities :
Attend to incoming calls from healthcare service providers and members / beneficiaries.
Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols and funding guidelines.
Loading of authorisations and the application of standard predictable within a telephone call.
Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation categories.
Clinical Risk Management to reduce the risks associated with hospitals and other authorised services.
Establish the presence of any co-morbid conditions from the caller or beneficiary if caller is not able to assist.
Refer to member management (case management) if co-morbid conditions are present for intervention and follow-up.
Attend to general enquiries.
Prepare and present cases for escalation to member management for discussion and resolution.
Provide member care and education to patients with and without chronic conditions who need to participate in any of the registered active disease management programs.
Minimum Requirements :
Registered / Enrolled Nurse
Valid registration with SANC
Minimum 2-3 years’ experience in a similar role within a managed healthcare or medical scheme environment
Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD
10’s, CPT4, NRPL, PMB conditions and clinical protocols
Thorough, well-grounded clinical knowledge of the pre-authorisation of hospital admissions (including Length of Stay and Level of Care), in-rooms procedures and other healthcare services requiring pre-authorisation
Excellent telephonic and written communication capability within a call centre environment (will be tested)
Computer literate (will be tested) – MIP Application System experience will be advantageous
Ability to liaise with external parties – clinicians and members – and to make decisions
Demonstrated ability to effectively deal with emotionally charged and stressful situations
Self-motivator and the ability to work effectively in an independent environment
Good organisational and task prioritisation skills
Proficiency in English – written and verbal (an additional language will be advantageous)
Ability to research and analyse information
High degree of accuracy and attention to detail
Compile and submit relevant reports in accordance with strict deadlines
Results orientated
Maintaining confidentiality of information
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Title: Member Care Clinical Consultant/Pre-authorisations
Company: H2R Africa
Location: Pretoria, South Africa
Category: Healthcare
