The Pre-Authorisation Nurse provides hospital utilisation management, education/training, and other clinically based activities as assigned, to coordinate care between the medical scheme/managed care organisation, members, providers and the community.
Preauthorisation is a 24/7/365 days service centre. Staff work on compressed hours which is done on a rotational basis.
Duties and Responsibilities
- Verifies eligibility of cover in accordance with medical scheme membership files and medical scheme rules.
- Required to work compress hours shift on a rotational basis.
- Authorises and facilitates admission of the member to a suitable facility subject to the clinical guidelines and protocols of the company.
- Authorises out of hospital visits to specialists.
- Establishes whether the member has any co-morbid conditions.
- Communicates with the admitting facility the details of the admission including the level of care, length of stay and value to the hospital as well as any conditions of the admission.
- Communicates with attending medical practitioner to request specific health information or discounts on specific procedures or equipment.
- Collaborates on a member’s care plan in conjunction with other health professionals such as the Medical Advisor, other Case Management nurses within the organisation, dieticians, podiatrists, optometrists, behavioural health specialists, etc, as the case may be.
- Refers patients to Disease Management, where appropriate, during a hospital admission.
- Updates the computer system with the member’s clinical and demographic details.
- Prepares, participates in discussions and presents cases at clinical meetings.
- Prepares reports and case summaries as needed.
- Completes special assignments and projects instrumental to the function of the department.
- Performs other duties as needed.
Experience and Qualifications Required
- Qualified as an Enrolled Nurse, Registered Nurse or Clinical Associate
- Must have a valid registration with applicable Health Professional Boards
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Minimum of 3 years’ experience in a call centre environment within a medical scheme or managed care environment.
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Experience with quality management, medical records reviews, case management within a hospital environment, primary care case management will be an advantage.
- Experience with chronic illnesses and targeted disease states.
- Understanding of the SA healthcare industry and the use of medical scheme / healthcare financing terminology.
Skills and Competencies Required:
- Strong verbal and written communications skills.
- Customer service focus.
- Ability to solve problems in a customer friendly manner.
- Attention to detail
- Critical thinking
- Time management
- Compassion
Language Requirements
- Writing and speaking fluent and correct English.
- Speaking and writing another language would be an advantage.
Registration Requirements
Current and continued registration with the SA Nursing Council.
Computer Literacy
Proficiency with the following programmes is required:
MS Word
MS Excel
MS Outlook / email
MS Explorer / Internet
Some prior knowledge/experience in the use of a medical aid administration or managed care system.
Work Requirements
- The position will be based in Sunninghill.
- Willingness to work long hours when required is a requirement.
Remuneration
- A competitive salary and benefits will be negotiated, consistent with experience and the role and responsibilities of the position.
Desired Skills:
- Strong verbal and written communications skills
- Time management
- Critical thinker
- Ability to solve problems in a customer friendly manner
- Customer service focus
- Atttention to detail
Desired Accreditations:
- South African Nursing Council
About The Employer:
Universal is a proud healthcare services group that is turning heads in the industry.
Our comprehensive and fully integrated portfolio of services sets a new benchmark in care management. Our brand promise is to deliver healthcare that combines business intelligence with excellence in healthcare management, packaged to meet each medical scheme and its members’ needs.
If you want to contribute significantly to the growth and development of an innovative company, be challenged in a line of work that really impacts people’s lives for good, and engage in a fantastic team environment, we’d like to hear from you.
Thank you for your interest in working for Universal Healthcare. Kindly note that your application will be reviewed in accordance to the job requirements and the Company will select suitable candidates with cognisance of its Employment Equity policy. Should no response be received within 30 working days from your date of submission, please consider your application unsuccessful for this position, your resume will remain active in our database should you be suitable for positions in future.
Employer & Job Benefits:
- Pension Fund
- Funeral Cover
- GAP Cover
- Medical Aid
- 360 Degrees Reward Programme