New and exciting vacancy available at this forward thinking and dynamic medical aid organisation based in Bryanston. Seeking the services of an experienced and dedicated Pre-Authorisation and Risk Management Consultant. Good personal attributes would be well organised, hardworking, and an ability to absorb pressure. Excellent future career prospects and opportunity for growth both personally and professionally.


Scope of responsibility:
? Overall responsibility for incoming and outgoing calls to and from members and healthcare practitioners relating to authorisations for procedures in healthcare practitioner rooms.
? Manages clinical risk by promoting sound principles and strategies to decrease claims over utilisation.
? Classifies and prioritises risks based on the frequency of member visits to a provider.
? Develop claims risk control strategies and protocols.
? Audit claims and work with healthcare practitioners and members to help resolve over utilisation of benefits.
? Analyses claims and loss ratios for trends or indication of patterns regarding clinical risks and provide reports with possible solutions for management review and approval.
? Facilitates root cause analysis and provides clinical insight and risk management strategies.
? Develop corrective action plans and monitors follow-up or recommend improvements stemming from risk assessments.
? Monitors clinical outcomes, corrective actions and strategies for effectiveness and makes recommendations to the management team.
? Provides on call assistance for emergent/urgent risk management issues as needed.
? Ensure efficient Customer Service and compliance to agreed SLA’s
? Follow up with healthcare practitioners and members who may be over utilising the “in rooms” procedures.
? Manage and maintain data integrity and update accordingly where necessary.
? Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.
? Weekly review of all approved claims and ensure that all are settled according to correct tariffs and procedures.
? Develop and supply all monthly management reports.
? Any other duties as assigned by your supervisor from time to time.

Qualifications skills and previous experience required:
? Matric
? Registered Nursing diploma
? Certified Health Care Risk Management certification or other risk management certification is an advantage
? Clinical qualification with clinical experience and ICD 10 Coding.
? Valid membership of SANC

? At least 3 years’ experience in a similar role.
? MIP Application System experience an advantage but is not essential
? Sound understanding of the South African Health Industry, benefits and options etc.
? ICD codes, modifiers and RPL tariff knowledge and understanding
? Ability to liaise with external parties – clinicians and members
? Ability to work within an established team
? Excellent oral and written communication skills
? Customer centric attitude
? Excellent analytical skills and pays attention to detail
? Computer literate - MS Office suite, i.e. Word, Excel
? Experience in claims risk profiling
? Experience in claims auditing