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 members by providing relevant clinical information to access the correct clinical benefits.
- Consult members' health care professionals to make informed clinical decisions and manage financial risk.
- Correctly escalate complex clinical calls.
- 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 .
#J-18808-Ljbffr
