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Prospective Reviewer (Pre-Authorisation Call Centre)
Palesa Mbali Group Tuesday, 05 November 2024 40Job Summary
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
Education and Experience:
- 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
Palesa Mbali Group
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