Title of vacancy:

Pre-Authorisation Case Manager and Clinical Auditor
Department: Medical and Surgical Risk Management
Manager: Senior Manager – Medical/Surgical Risk Management
EE/AA candidates only

Area:
Sandton, Johannesburg

Package:
The Annual total cost to company ranges between R325 000.00 and R390 000.00 (depending on qualifications and experience)

Duties:
Pre-authorisation
• Liaise with the Medical Advisor
• Pre-authorise members admissions to hospital according to departmental protocols and
• guidelines
• Pre-authorise specialist referrals and specialised radiology
• Capture the authorisation on the Imed system
• Handle hospital updates telephonically and via e-mail
• Telephonic case management (monitoring of ongoing cases) and referral of cases for intensive case management
• Final updates with hospitals and discount negotiations
• Handle member queries re hospitalisation and benefits
• Handle written communication including reports of motivation and correspondence
• Request reports from attending practitioners
• Provide weekly/monthly/quarterly/ad hoc reports to management and scheme
• Manage cost containment of hospital incidents
• Schedule the weekly roster for the call centre
• Ensure maintenance of the Call Centre’s SLA’s
• Liaise with the hospital/doctor/member/family
• Work with other healthcare personnel within the organisation and with the client
• Provide clinical expertise within the organisation and to the client where required
• Ensure good communication between various departments
• Hours of work – rotation as per the pre-authorisation call centre roster
• Multiskilled in the case management area in order to cover all areas when staff are not available
• Ad hoc duties

Clinical Auditing
• Vet hospital account under the guidance of the Gazette and process associated claims
• according to BHF and SAMA guidelines
• Use clinical guidelines and protocols when vetting accounts
• Liaise with other members of the team and other departments
• Align hospital and associated accounts with hospital authorisations on system
• Daily auditing of accounts both hospital and associated
• Checking accounts for non-chargeable items – as per gazette
• Evaluation of accounts for technical correctness using sound medical judgement
• Able to reconcile hospital accounts
• Able to deal with external auditors queries re payments of hospital claims
• Involved with mapping of new tariffs
• Multiskill between capturing/editing/auditing
• Provide weekly/monthly reports to management
• Investigate claims against daily reports
• Capture authorisations on the Imed system
• Handle member/hospital queries re account payments
• Schedule the monthly roster for the clinical auditor duties
• Liaise with the Medical Advisor
• Work with other healthcare personnel within the organisation and with the client
• Provide clinical expertise within the organisation where required
• Ensure good communication between various departments
• Ensure maintenance of SLA’s
• Ad hoc duties


Formal Education:
• Code 08 Driver’s License
• Must have own vehicle and be prepared to travel as far as Welkom
• Nursing Qualification (Nursing Diploma as a registered nurse or enrolled nurse)
• Previous pre-authorisation and clinical auditing experience in a managed healthcare environment is essential


Knowledge and Skills:
• Excellent command of the English language and fluency in at least 2 African languages
• Computer literacy essential – windows packages especially Microsoft Word and Excel
• Excellent telephonic communication skills
• Logical thinker
• Excellent report writing skills
• Able to apply clinical knowledge
• Good organisational skills
• Good time management skills
• Able to problem solve
• Excellent knowledge of ICD 10 codes, CPT 4 codes and Prescribed Minimum Benefits
• Able to negotiate discounts with providers

Personality Requirements:
• Ability to develop good working relationships with work colleagues – a team player
• Able to handle stress – work to deadlines
• Self-motivated who takes personal responsibility for developing excellence
• Positive attitude and pro-active
• Ability to communicate on all levels
• Able to maintain a high level of confidentiality
• Honest/compassionate/empathetic
• Portray a professional image
• Work to a high standard of excellence, paying attention to detail and time
• Be flexible and adaptable – regarding hours of work, tasks and duties
• Customer centric
• Interact with people in an appropriate manner – always polite, empathetic or assertive where necessary/good interpersonal skills
• Punctual