Together with our client, we are recruiting for a Clinical Case Manager (Call Centre) in Pretoria. The Candidate must be a Registered Nurse with SANC and have at least two years’ experience in the private healthcare sector. Previous experience working at a Medical Aid Scheme would be an advantage.
Duties and Responsibilities
Receive applications for all services which require pre-authorisation.
Handling of telephonic authorisations, hospital, radiology and specialist referrals on the pre-authorisation call centre.
Capture clinical information and verify the information, including the aplicable ICD-10 and item codes.
Confirm membership status & available benefits on the system before authorisation can be granted.
Validate and evaluate special pre-authorisation requests.
Ensure that the correct codes are used before benefits are approved.
Clinical interpretation and analysis of medical reports and/or doctor’s motivation.
Provide correct applicable information in respect of scheme rules, benefits & 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.
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
A completed degree/diploma as a registered nurse and must be registered with SANC.
Two year’s relevant experience in a private hospital.
Comprehensive knowledge of the Medical Schemes Act.
Sound knowledge of CPT-4 & ICD-10 codes RPL.
Must possess the following skills:
Technical and professional knowledge and skills;
Good verbal and written English communication skills as well as proficiency in understanding Afrikaans spoken and written communication
Must work well with people and be able to handle conflict situations