Established company in managed healthcare is looking for Enrolled/ Registered Nurses with clinical AND medical aid environment experience to apply.

Qualifications & Experience that will be considered for this position:
B Cur Degree / Diploma in Nursing
Min 2 years clinical experience
Min 1 year medical aid experience
Medical Scheme – related experience in Hospital Benefit Management

Knowledge required for this position:
Thorough, well-grounded clinical knowledge of Pre Authorization of hospital admissions and Case Management of hospital cases in order to take cost-effective and appropriate decisions in evaluating treatment, LOS and LOC.
Knowledge of the current coding structures in the South African Health Care environment i.e. ICD10’s, CPT4, NRPL, and PMB conditions, protocols and Scheme rules

Job Description:
1. To provide pre-authorisation for hospitalisation, specialist visits, out of network visit, MRI, CT scanning, Step down facilities and home nursing.
2. Pre-auth should be granted inside the prescribed protocols and Scheme Rules
3. Clinical proof for new members and or dependants, who are being monitored, should be received before pre-authorizations are given.
4. Accomplishing member satisfaction by delivering outstanding client services together with satisfactory productivity.
5. To ensure that telephone calls are been answered within 85% of the service level to achieve member satisfaction
6. To maintain good relations with clients and personnel at all times.
7. To ensure that the case managers Department and Pre-authorisation department work well together in a team at all times.