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.
Duties & 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.
Desired Experience & Qualification
Qualifications:
Registered Nurse
Valid registration with SANC
Skills and Competencies Required:
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