Pre-Auth Clinical Consultant x2
Job description
Job Description
To promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. The ideal candidate for this position is an energetic professional who is able to foster relationships with staff at assigned hospitals to improve coordination of care at appropriate levels. Adhere to workflow standard according to policies and procedures and apply knowledge of the current Medical Schemes Act and accompanying regulation as well as handling of queries effectively and efficiently and at the same ensuring proposed clinical procedures and length of stay are appropriate.
Duties & Responsibilities
- Validation of membership and benefits availability according to Pre-authorization policies and procedures
- Authorization of procedures and admission to hospital based on medical necessity
- Contact relevant suppliers regarding acceptance or denial of authorization within 24 hours prior to admission
- Source appropriate information to resolve issues
- Record all authorizations and queries handled
- Prepare cases for review by the medical advisor
- Identify and document patients with chronic conditions
- Fostering relationships with staff at assigned hospitals to improve coordination of care at appropriate levels
- Handling of queries effectively and efficiently.
- Ensure proposed clinical procedures and length of stay are appropriate
- Provide patients with pre-operation instructions
- Adhere to Call Centre standards of above 97% calls answered
- Meet call Centre daily targets according to company service level agreements
- Adhere to workflow standard according to policies and procedures
- Apply knowledge of the current Medical Schemes Act and accompanying regulation
- Oversee the intercompany transactions – lead internal intercompany confirmations on a quarterly basis
Qualifications
• Matric • Registered/ enrolled nurse (with SANC) with 3 years relevant nursing experience in the Medical Aid sector • Computer Literate • Proficiency and fluency in English and another official language • Excellent Telephone Manner • Good communication and interpersonal skills with customer focus. • Previous Pre-authorizations experience would be advantageous • Sound knowledge of Prescribed Minimum Benefits • Sound knowledge of National Reference Price list remove • Basic knowledge of ICD 10 and CPT coding Core Competencies • Ability to work under pressure and as part of a Team
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