Pre-Authorisation Nurse - National Risk Managers (Pty) Ltd

A Medical Insurance Company based in Benoni is looking for a Pre-Authorisation Nurse who will assess the authenticity and legitimacy of requests for medical services or treatment by members or service providers in a timely, effective, efficient, equitable and client centred manner.

Key Performance Areas

Authorise or Decline Medical Services or Treatment
Mitigate Waste or Abuse of Benefits
Undertake General Administrative Duties

Key Tasks

Authorise or Decline Medical Services or Treatment

Validate membership status and available benefits based on plan type
Confirm compliance with policy terms and condition, waiting periods and exclusions
Approve or decline benefits strictly according to the benefits applicable per benefit option and protocols
Conduct official security checks before information is disclosed to clients
Refer authorisation or declination to relevant case management team

Mitigate Waste Or Abuse Of Benefits

Assess pre-authorisation requests for GP visits, specialist visits, emergency room visits, diagnostic procedures and hospitalisation for illness and accident events
Request applicable documentation (e.g. medical history, motivational letter or accident report) before a final assessment to approve or decline can be made
Assess continuation of benefits and applicable cover limits
Exclude possible non-disclosure of pre-existing conditions
Check that the reasons provided for authorisation and documentation received are appropriate and are according to set protocols, guidelines, formularies and preferred provider agreements.
Assess pre-authorisation requests for appropriate alternative facilities (i.e., Day clinics, Sub-Acute facilities, Home Nursing and preferred providers)
Utilise cost effective network providers and appropriate alternative facilities
Escalate the case for a clinical review if the reason for authorisation is not defined in the protocols or guidelines
Provide correct information in respect of preferred providers or alternative facilities in respect of all services required by patients or service providers.
Provide correct information in respect of policy terms and conditions and benefits
Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems

Undertake General Administrative Duties

Prioritize incoming authorization requests and/or queries according to urgency.
Process upfront payment request according to protocol
Determine the urgency of the upfront payment as indicated by comparing the payment and admission dates
Capture all relevant information, as well as approved documents, on the appropriate operational systems
Provide members and applicable provider(s) with verbal and/or written notification with regards to the outcome of the pre-authorisation request.
Handle and escalate appeals on decline authorisation requests and complaints to the clinical review team
Utilise the Intranet system to obtain all latest updated documents before sending to clients
Maintain confidentiality and conduct relevant security checks before information is disclosed to clients
Adhere to all verbal or written instructions and comply with Company policies and Regulator requirements
Maintain strict compliance with Company policies and Regulator's requirements
Adhere to and maintain set turnaround times and SLAs (e.g., Calls, PCMs. WhatsApp (Apex) and emails)
Comply with training and coaching deadlines and QA pass rates

When the job will be performed