About the position
Clinical Consultant Pre-authorisations
Department: Member Care
Remuneration: Competitive market-related CTC package, including medical aid and provident fund
Working Hours: 8 hour Rotational shifts between 07h00 and 19h00 (Monday to Sunday) - Time off in lieu of weekend worked (enquire for further detail)
Pretoria based Managed Care Organisation specialising in integrated clinical management services to low-income medical schemes seeks to employ a Clinical Pre-Authorisation Consultant to their team.
Minimum Qualifications:
- Registered or Enrolled Nurse (Diploma/ Degree)
- Current SANC Registration is essential
Required Skills & Competencies:
- 2-3 years of Pre-authorisation experience within a managed healthcare or medical scheme setting
- Exceptional verbal and written communication skills, particularly in a call centre environment (assessment will be conducted)
- Proficient in computer systems (assessment will be conducted); experience with MIP and/or MedCaps applications is beneficial
- Strong customer service orientation with the ability to engage effectively with external stakeholders, including healthcare providers and scheme members
- Capacity to manage high-pressure situations with professionalism and empathy
- Self-driven and capable of working independently
- Excellent organisational and prioritisation abilities
- Multitasking proficiency
- Fluent in English (written and spoken); an additional language would be advantageous
- Strong analytical and research skills
- High level of accuracy and attention to detail
- Ability to compile and submit reports within strict deadlines
- Results-driven approach
- Commitment to maintaining confidentiality
- Strong understanding of the South African healthcare sector, industry regulations, and medical coding structures (ICD-10, CPT-4, NRPL, PMB conditions, and clinical protocols) Testing on procedure codes will be conducted
- Solid clinical expertise in pre-authorising hospital admissions, including length of stay, level of care, in-room procedures, and other healthcare services requiring prior approval
Key Responsibilities:
- Handle inbound calls from healthcare providers and medical scheme members regarding pre-authorisations
- Verify benefit eligibility according to scheme rules, clinical protocols, and funding guidelines
- Process authorisations and apply standard protocols within a telephonic interaction
- Ensure strict compliance with scheme benefits, rules, and clinical guidelines for all service authorisations
- Perform clinical risk assessments to mitigate risks associated with hospital admissions and other pre-authorised healthcare services
- Identify any co-morbid conditions and escalate cases to case management for further intervention if necessary
- Respond to general inquiries related to benefits and authorisations
- Present complex cases to case management for further assessment and resolution
- Educate members on healthcare processes and guide those with chronic conditions into active disease management programs
Ready to take on this exciting challenge?
Please apply to response "at" [URL Removed] REF: MVG/PAuthPret.
Supporting Documents Required:
- Copy of Comprehensive CV detailing Pre-Auth experience
- Copy of SANC Registration
- Copy of Nursing Diploma
- Copy of Matric Certificate
Desired Skills:
- 2-3 years of Pre-authorisation experience within a managed healthcare or medical scheme setting
Desired Work Experience:
Desired Qualification Level & Accreditations:
- Diploma
- South African Nursing Council
