Member Care Clinical Consultant (Pre-authorisations)

SUMMARY:
Ensuring that healthcare services requiring pre-authorization are evaluated and processed

POSITION INFO:

Our client in the Medical Industry, based in Pretoria, has a Permanent vacancy for a Member Care Clinical Consultant (Pre-Autorisation).

Job Purpose:
The role of a Member Care Clinical Consultant (Pre-Authorisations) involves ensuring that healthcare services requiring pre-authorization are evaluated and processed efficiently, aligning with medical necessity and policy guidelines.

Responsibilities:

• Attend to incoming calls from healthcare service providers and members/ beneficiaries.
• Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols and funding guidelines.
• Loading of authorisations and the application of standard predictable within a telephone call.
• Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation categories.
• Clinical Risk Management to reduce the risks associated with hospitals and other authorised services.
• Establish the presence of any co-morbid conditions from the caller or beneficiary if caller is not able to assist.
• Refer to member management (case management) if co-morbid conditions are present for intervention and follow-up.
• Attend to general enquiries.
• Prepare and present cases for escalation to member management for discussion and resolution.
• Provide member care and education to patients with and without chronic conditions who need to participate in any of the registered active disease management programs.

Minimum Requirements:

• Registered/ Enrolled Nurse
• Valid registration with SANC
• Minimum 2-3 years’ experience in a similar role within a managed healthcare or medical scheme environment
• Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10’s, CPT4, NRPL, PMB conditions and clinical protocols
• Thorough, well-grounded clinical knowledge of the pre-authorisation of hospital admissions (including Length of Stay and Level of Care), in-rooms procedures and other healthcare services requiring pre-authorisation
• Excellent telephonic and written communication capability within a call centre environment (will be tested)
• Computer literate (will be tested) - MIP Application System experience will be advantageous
• Customer service orientation
• Ability to liaise with external parties – clinicians and members – and to make decisions
• Demonstrated ability to effectively deal with emotionally charged and stressful situations
• Self-motivator and the ability to work effectively in an independent environment
• Good organisational and task prioritisation skills
• Outstanding multitasking skills
• Proficiency in English – written and verbal (an additional language will be advantageous)
• Ability to research and analyse information
• High degree of accuracy and attention to detail
• Compile and submit relevant reports in accordance with strict deadlines
• Results orientated
• Maintaining confidentiality of information