PRE AUTH CASE MANAGER at MEDICAL SCHEME

About the position

Responsible for basic telephoni case managment of cases which are monitored from admission through to discharge so that there is complete understanding of patient progress

Pre Authorise members admission to hospital according to scheme benefits and departmental protocols and guidelines
Manage high cost and general ward cases up to the value of R70k
Telephonic case management of surgical cases and medical cases excluding joint replacements

kEY RESPONSIBILITIES

• Pre authorise member's admission to hospital as per scheme protocol and guidelines
• Capture authorization on IMED system
• Liaise with medical advisor
• Handle hospital updates telephonically and via e-mails
• Telephonic and e-mail case management and referral of cases for Specialised case management as per guidelines
• Monitoring of ongoing hospital cases and final updates including negotiating for discounts
• Handle member's queries regarding hospitalization and benefits
• Handle written communication and motivation reports including correspondence
• Manage cost containment of hospital incidents/admissions
• Ensure maintenance of call centre SLA
• Liaise with hospitals, doctors, members and family members
• Work with other healthcare personnel within the organisation
• Provide clinical expertise within the organisation where required
• Ensure good communication inter departmentally
• Performing ad hoc duties
• Manage general ward and high care cases up to R70 000
• Physical rehabilitation and step-down admission on cases managed by pre authorizations
• Negotiating internal prosthesis discounts and reporting the savings

QUALIFICATIONS

Registered or Enrolled Nurse with 3-5 years pre-auth case management experience
Extensive knwledge of Tariff and Nappi Codes, Modifiers, Practice Types, ICD 10 codes and CPT coding
Knowledge of PMB Conditions and related rules
Knowledge of iMed/Cubed system

Desired Skills:

• REGISTERED OR ENROLLED NURSE
• CASE MANAGEMENT AND PRE-AUTH EXPERIENCE IS ESSENTIAL
• MANAGED HEALTHCARE