Prospective Reviewer (pre Authorisation Call Centre)
Johannesburg, Gauteng, South Africa
Job Description
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
- 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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Job Detail
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Job IdJD1335054
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IndustryNot mentioned
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Total Positions1
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Job Type:Full Time
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Salary:Not mentioned
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Employment StatusPermanent
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Job LocationJohannesburg, Gauteng, South Africa
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EducationNot mentioned