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Job Summary
Prospective Reviewer (Pre-Authorization Call Centre)
The Prospective Reviewer role within the pre-authorization call centre, is responsible for authorizing hospital authorization requests ensuring that requirements of clinical appropriateness, medical necessity and clinical risk management are met.
Key Activities:
- Authorizing 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
- Minimum of 3 years in the clinical space required
- Must be computer literate
- Call centre experience advantageous
- Previous Managed Healthcare experience in a call centre environment – advantageous
Company Description:
A highly respected company with many of the top medical schemes under their umbrella
Palesa Mbali Group
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