Pre-Authorisation Nurse - Johannesburg, South Africa - National Risk Managers

    National Risk Managers
    National Risk Managers Johannesburg, South Africa

    2 weeks ago

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    Description
    A Medical Insurance Company based in Benoni is looking for a Pre-Authorisation Nurse who will assess the authenticity and legitimacy of requests for medical services or treatment by members or service providers in a timely, effective, efficient, equitable and client centred manner.

    Key Performance Areas
    • Authorise or Decline Medical Services or Treatment
    • Mitigate Waste or Abuse of Benefits
    • Undertake General Administrative Duties
    Key Tasks
    Authorise or Decline Medical Services or Treatment
    • Validate membership status and available benefits based on plan type
    • Confirm compliance with policy terms and condition, waiting periods and exclusions
    • Approve or decline benefits strictly according to the benefits applicable per benefit option and protocols
    • Conduct official security checks before information is disclosed to clients
    • Refer authorisation or declination to relevant case management team

    Mitigate Waste or Abuse of Benefits
    • Assess pre-authorisation requests for GP visits, specialist visits, emergency room visits, diagnostic procedures and hospitalisation for illness and accident events
    • Request applicable documentation (e.g. medical history, motivational letter or accident report) before a final assessment to approve or decline can be made
    • Assess continuation of benefits and applicable cover limits
    • Exclude possible non-disclosure of pre-existing conditions
    • Check that the reasons provided for authorisation and documentation received are appropriate and are according to set protocols, guidelines, formularies and preferred provider agreements.
    • Assess pre-authorisation requests for appropriate alternative facilities (i.e., Day clinics, Sub-Acute facilities, Home Nursing and preferred providers)
    • Utilise cost effective network providers and appropriate alternative facilities
    • Escalate the case for a clinical review if the reason for authorisation is not defined in the protocols or guidelines
    • Provide correct information in respect of preferred providers or alternative facilities in respect of all services required by patients or service providers.
    • Provide correct information in respect of policy terms and conditions and benefits
    • Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems


    Undertake General Administrative Duties
    • Prioritize incoming authorization requests and/or queries according to urgency.
    • Process upfront payment request according to protocol
    • Determine the urgency of the upfront payment as indicated by comparing the payment and admission dates
    • Capture all relevant information, as well as approved documents, on the appropriate operational systems
    • Provide members and applicable provider(s) with verbal and/or written notification with regards to the outcome of the pre-authorisation request.
    • Handle and escalate appeals on decline authorisation requests and complaints to the clinical review team
    • Utilise the Intranet system to obtain all latest updated documents before sending to clients
    • Maintain confidentiality and conduct relevant security checks before information is disclosed to clients
    • Adhere to all verbal or written instructions and comply with Company policies and Regulator requirements
    • Maintain strict compliance with Company policies and Regulator's requirements
    • Adhere to and maintain set turnaround times and SLAs (e.g., Calls, PCMs. WhatsApp (Apex) and emails)
    • Comply with training and coaching deadlines and QA pass rates
    When the job will be performed
    • 12 hours, Rotational Shifts – Day and Night
    • 07h00 to 19h00 and 19h00 to 07h0
    Essential Qualifications
    • Matric
    • Diploma or Degree in Nursing as a Registered Nurse
    Desirable Qualifications
    • ICD 10 coding course and/or
    • BHF coding course, and/or
    • CPT coding course
    Legal or Statutory Requirements
    • Registered with SANC
    Desirable Experience
    • Managed Health Care in a Contact Centre environment
    • Theatre and/or ICU experience
    Knowledge and Skills
    • Computer literate
    • Demonstrable Administration skills
    • Working knowledge of ICD, BHF and CPT Codes
    Attributes
    • Professional
    • Flexible
    • Detail oriented
    • Responsible & Accountable
    • Honest, Hardworking and Humble