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Pre-Authorisation Consultant

Edge Executives • Other • Johannesburg, South Africa • 2d ago

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.

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