Pre Authorisation Consultant

Gauteng, South Africa

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Job Summary Requirements:

Nursing diploma (enrolled or registered nurse) or paramedic qualification.
35 years of experience in pre-authorization within managed healthcare.
Knowledge of PMB conditions, clinical guidelines, ICD-10 codes, and hospital systems.
Familiarity with medical scheme regulations and billing procedures.

Key Responsibilities:

Authorize hospital admissions per scheme guidelines.
Verify in-hospital benefits and funding.
Manage surgical and medical cases within defined cost limits.
Handle queries related to designated service providers, co-payments, and penalties.
Refer complex and high-cost cases for further review.
Maintain up-to-date knowledge of product changes and clinical guidelines.
Achieve service delivery targets, including call center SLAs.

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