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    Prospective Reviewer - Johannesburg, South Africa - Palesa Mbali Group

    Palesa Mbali Group
    Palesa Mbali Group Johannesburg, South Africa

    Found in: Talent ZA C2 - 5 days ago

    Default job background
    Full time
    Description

    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
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