Job Description

Our client based in Nelspruit is looking to appoint a Clinical Benefits Agent.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.PRIMARY DUTIES

• Pre-Authorisations

• Evaluate and process requests for pre authorizations for medical procedures and treatments.
• Ensure all necessary information is gathered to make informed authorization decisions.
• Communicate authorization decisions to healthcare providers and members promptly.
• Case Management

• Monitor and manage individual patient cases to ensure appropriate care and efficient use of resources.
• Coordinate with healthcare providers to develop and implement care plans.
• Follow up on patient progress and adjust care plans as needed
• Communication

• Serve as a liaison between members, client relations, and healthcare providers.
• Facilitate clear and effective communication to ensure all parties are informed about authorization decisions, care plans, and any changes.
• Address inquiries and resolve issues related to pre-authorizations and case management.
• Draft and send letters to the above regarding exclusions, pre-authorizations etc.
• Negotiation of Tariffs

• Negotiate tariffs and fees with healthcare providers to ensure cost-effective care for members.
• Ensure that negotiated tariffs comply with organizational policies and regulatory requirements.
• Maintain accurate records of tariff agreements and monitor adherence to agreed terms.
• Risk Management

• Identify potential risks associated with patient care and preauthorization processes.
• Develop and implement strategies to mitigate identified risks.
• Monitor the effectiveness of risk management strategies and make adjustments as needed.
• POPIA

• Maintain the highest level of confidentiality and security when handling sensitive personal/medical information in accordance with the client's Policies and POPI Act.
• Handle personal and medical information securely. All information coming into the client should only be shared with authorized personnel and used for legitimate business purposes.
• Cooperate fully during compliance audits to ensure adherence to the POPI Act, especially regarding the processing of health-related information.

• Matric with mathematics
• Diploma in business, risk or clinical nursing advantageous
• Knowledge of Anatomy and Physiology advantageous.
• Previous experience in case management, pre-authorizations, or a similar role strongly
• Strong negotiation and communication skills.
• Ability to manage multiple tasks and work under pressure.
• Knowledge of healthcare regulations and compliance requirements strongly
• Knowledge of different COID and Medical Aid rules and managed health care policies.
• Proficiency in using case management software, ICD10codes and procedure codes strongly

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