SUMMARY:
Our client is looking for a Pre-Authorisation Consultant that will assess and manage pre-authorisation requests for hospital admissions, procedures, and treatments. The role requires a strong clinical background and experience in a hospital environment to ensure appropriate care while controlling healthcare costs. The Pre-Authorisation Consultant works closely with healthcare providers, members, and internal teams to ensure compliance with clinical guidelines and medical aid policies.
POSITION INFO:
Key Responsibilities:
- Pre-Authorisation of Hospital Admissions and Procedures:
- Evaluate and approve pre-authorisation requests for hospital admissions, surgeries, and specialised medical treatments.
- Assess medical necessity and appropriateness based on clinical guidelines, scheme rules, and patient history.
- Review hospital documentation, including treatment plans, diagnostic reports, and clinical assessments to ensure appropriateness of care.
- Clinical Collaboration:
- Liaise with doctors, specialists, and hospital staff to obtain necessary medical information for authorisations.
- Communicate effectively with healthcare providers to clarify treatment protocols and authorisation decisions.
- Provide advice on alternative treatment options when necessary to align with the clinical and financial guidelines of the medical scheme.
- Documentation and Reporting:
- Maintain thorough records of all pre-authorisation decisions and ensure compliance with audit and reporting requirements.
- Prepare reports and analysis on hospital pre-authorisation trends, approval rates, and cost implications.
- Risk and Compliance Management:
- Identify potential risks in hospital care plans, providing recommendations to mitigate unnecessary expenses and maintain quality of care.
- Ensure compliance with all healthcare regulations and scheme rules related to hospital care and authorisation processes.
Key Skills & Competencies:- Advanced clinical knowledge, particularly in a hospital environment.
- Familiarity with hospital care workflows, surgical procedures, and inpatient management.
- Strong understanding of managed care principles and medical aid regulations.
- Excellent communication and collaboration skills for working with hospital staff and healthcare providers.
- Strong decision-making skills, with the ability to evaluate clinical risks and financial impacts.
- Proficiency in medical coding and understanding of hospital billing processes.
Minimum Requirements:- Education: Registered Nurse (with SANC)
- Professional Membership: Registered with the South African Nursing Council (SANC)
- Experience: At least 3-5 years of clinical experience, with significant exposure to a hospital environment, including ICU, surgical, or medical ward experience. Prior experience in managed care, case management, or pre-authorisation is an advantage.
- Skills: Proficiency in clinical assessments, understanding of hospital-based treatments, and working knowledge of healthcare systems/software.