• My client within the medical aid scheme has an exciting opportunity for a Clinical Pre-Authorization Consultant (Call Centre) 2) with years’ experience working in a private hospital and must have knowledge of CPT-4 and ICD-10 codes RPL.

Qualifications and Experience:

• Matric
• Registered Nurse with at least two (2) years’ experience in a private hospital.
• Comprehensive knowledge of the Medical Schemes Act.
• Sound knowledge of CPT-4 and ICD-10 codes RPL.
• Must be registered at SANC
• Must be computer literate
• Must have good verbal and written English communication skills as well as proficiency in understanding Afrikaans spoken and written communication skills.
• Must work well with people, and be able to handle conflict situations

Job Responsibilities:

• Receive applications for all services which require pre authorization.
• Handling of telephonic authorizations, hospital, radiology and specialist referrals on the pre-authorization Call Centre.
• Deliver a high quality service to the members and service providers.
• Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems.
• Validate and evaluate special pre-authorization requests.
• Ensure that the correct codes are used before benefits are approved.
• Clinical interpretation and analysis of medical reports and/or doctor’s motivation.
• Capture clinical information and verify the information, including the applicable ICD-10 and item codes.
• Confirm membership status and available benefits on the system before authorization can be granted.
• Provide correct applicable information in respect of scheme rules, benefits and approvals in respect of all services requiring to patients and service providers.
• Approve benefits accurately according to the benefits per benefit option and strictly according to the protocols to reduce the Scheme’s risk in respect of benefits.
• Accurate and complete capturing of all relevant information as well as approved documents on the appropriate operational systems.