5 Medical Pre Authorisation jobs in South Africa

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Are you eager to grow and join a highly specialised team in the area of medical debt management? Become part of an exciting service based solution driven on the back of cutting edge healthtech, artificial intelligence and debt management processes.

As a Medical Claims Administrator , you will be required to deliver an efficient , consistent and accurate administrative medical debt service to clients. You will also provide the Doctors with monitoring and bureau reports that will allow them to have real time data on the financial status of their practice. You will become a trusted business partner ensuring that their cash flow is timeous and that aged debt is at a minimum.

Key Responsibilities:

• Capture patient demographics and claims accurately.
• Ensure that all claims are accurate before they are submitted to the Medical Schemes
• Clear claim rejections as soon as notified.
• Reconcile and monitor all remittances.
• Follow-up on all outstanding claims.
• Maintain a low age analysis.
• Follow up on short payments.
• Follow up on claims regularly with valid updates at each point of query.
• Keep constant communication open with the practice and the client.
• Build and maintain relationships with clients.
• Monitor and maintain doctors' databases.

Qualifications and Experience

• Matric
• A relevant administrative qualification is advantageous
• 2 to 3 years industry experience is essential
• Must have knowledge on PMBs

Knowledge and Skills

• Must have knowledge on PMBs
• High level of computer literacy
• High level of numeracy
• Google Workspace experience is advantageous

The salary bracket for the role is around R15k CTC p/m. Note that it is the client's prerogative, regardless of advertised package, to offer a market related salary considering the candidate's qualifications, skills, and level of experience.

• Seniority level Associate

• Employment type Full-time

• Job function Health Care Provider and Administrative
• Industries Medical Practices and Hospitals and Health Care

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Medical Claims AdministratorReference : PTA-CB-2We are looking for a Medical Claims Administrator for a big, amazing and innovative company in the health tech space.Duties & ResponsibilitiesThe purpose of the team that you will become part of is to launch a service-based solution driven by cutting-edge health tech, artificial intelligence, and debt management processes (primarily focused on the private medical specialists market).

You will focus strongly on client delivery and at the same time make a difference in the lives of doctors and patients alike.

You will deliver an efficient, consistent, and accurate administrative medical debt service, providing the doctors with monitoring and bureau reports that will allow them to have real-time data on the financial status of the practice.

You will become their trusted business partner, ensuring that their cash flow is timely and that their aged debt is at a minimum.Duties : Ensure that all claims are accurate before they are submitted to the medical schemes.Clear claim rejections as soon as you are notified.Reconcile and monitor all remittance advices.Select correct scheme agreements so that the client is able to post the correct rates annually.Follow up on all outstanding claims.Re-submit outstanding claims that need fixing.Maintain a low age analysis if not zero.Follow up on short payments.Follow up on claims regularly with valid updates at each point of query.Keep constant communication open with the practice and the client.Build and maintain relationships with clients.Monitor and maintain doctors databases with the assistance of BI reporting.Qualifications and Skills : Matric and relevant administrative qualification.G-Suite experience is advantageous.2-3 years industry knowledge.Must have knowledge on PMB's.Customer service oriented.Initiative and commitment to achieve.Attention to detail and quality.Teamwork oriented.Excellent communication skills.Diplomacy.Presentation skills.Adaptability.Analytical thinking.Continuous learning.Package & RemunerationR - R - MonthlyNOTE : We ONLY accept online applications.

We do not consider direct applications via WhatsApp or email.

SALARY DISCLAIMER : The advertised salary range is merely a guideline to attract a range of potentially suitable candidates to the advertised position.

This doesn't automatically mean that a successful candidate can claim an offer for the maximum advertised salary.

It is the prerogative of the future employer to offer a candidate a market-related remuneration package in line with the candidate's qualifications, skills, and level of experience.

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Medical Administrator • Durban, KwaZulu-Natal

Our client operating in the medical insurance space is seeking a Medical Claims Clinical Auditor to join their team based in Port Elizabeth - on a 6 month fixed term contract.
Nursing Diploma or Degree essential!
EE candidate preference.
An awesome career opportunity awaits!

Role Purpose
The purpose of this temporary role is to ensure hospital claims are audited timeously and accurately with the focus on reducing wastage and abuse, as well as to ensure that claims are processed according to authorizations for a period of 6 months only.

Requirements

• A National Senior Certificate is essential.
• It is essential to have a Nursing Diploma or Degree.
• The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse.
• MS Office / Office 365 proficiency.
• Minimum of 2 years’ private hospital nursing experience.
• Previous exposure to clinical auditing is highly advantageous.
• Be available to work at one of our offices based in Richmond Hill (Gqeberha), Cornubia (Durban), Bellville (Cape Town) or Centurion.

Responsibilities

INTERNAL PROCESS

• Apply scheme rules, clinical policies and protocols to funding.
• Action allocated hospital claims for audit within department KPIs and CMS requirements for claims payment.
• Ensure accurate notes are made for all journals actioned on claims audited.
• Assess prosthesis for PMB funding when benefits are exceeded or if there is no benefit.
• Ensure accurate completion of authorizations on claim finalization.
• Refer LOC/ LOS / item or drug approval queries to case managers for resolution.
• Act as clinical support to non-clinical hospital claim auditors in terms of hospital tariff applications and clinical guidance (e.g. procedures, devices and drug utilization).
• Survey claims for correct application of tariff and refer discrepancies to the relevant team.
• Review retrospective claim approvals and send journal instructions for additional payments to the relevant team.
• Review hospital claims for clinical appropriateness, treatment authorized, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.

CUSTOMER SERVICE

• Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timeous feedback.
• Escalate queries to the relevant team or stakeholder.
• Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
• Resolve claim queries accurately and timeously.
• Build and maintain relationships with internal and external stakeholders.
• Reduce claim rejections to ensure members are not held liable for unnecessary costs.

PEOPLE

• Build strong relationships through expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.

FINANCE

• Identify opportunities to enhance cost effectiveness and increase operational efficiency.
• Manage financial and other company resources under your control with due respect.
• Provide input into the risk identification processes and communicate recommendations in the appropriate forum.

Competencies

• Teamwork
• Examining information (interrogate claims data)
• Articulating information
• Upholding standards
• Accountability
• Attention to detail
• Time management

Please consider your application unsuccessful if you are not contacted within two weeks of applying.

Monthly

Our client operating in the medical insurance space is seeking a Medical Claims Clinical Auditor to join their team based in Port Elizabeth - on a 6 month fixed term contract.
Nursing Diploma or Degree essential!
EE candidate preference.
An awesome career opportunity awaits!

Role Purpose
The purpose of this temporary role is to ensure hospital claims are audited timeously and accurately with the focus on reducing wastage and abuse, as well as to ensure that claims are processed according to authorizations for a period of 6 months only.

• A National Senior Certificate is essential.
• It is essential to have a Nursing Diploma or Degree.
• The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse.
• MS Office / Office 365 proficiency.
• Minimum of 2 years’ private hospital nursing experience.
• Previous exposure to clinical auditing is highly advantageous.
• Be available to work at one of our offices based in Richmond Hill (Gqeberha), Cornubia (Durban), Bellville (Cape Town) or Centurion.

• Apply scheme rules, clinical policies and protocols to funding.
• Action allocated hospital claims for audit within department KPIs and CMS requirements for claims payment.
• Ensure accurate notes are made for all journals actioned on claims audited.
• Assess prosthesis for PMB funding when benefits are exceeded or if there is no benefit.
• Ensure accurate completion of authorizations on claim finalization.
• Refer LOC/ LOS / item or drug approval queries to case managers for resolution.
• Act as clinical support to non-clinical hospital claim auditors in terms of hospital tariff applications and clinical guidance (e.g. procedures, devices and drug utilization).
• Survey claims for correct application of tariff and refer discrepancies to the relevant team.
• Review retrospective claim approvals and send journal instructions for additional payments to the relevant team.
• Review hospital claims for clinical appropriateness, treatment authorized, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.

• Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timeous feedback.
• Escalate queries to the relevant team or stakeholder.
• Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
• Resolve claim queries accurately and timeously.
• Build and maintain relationships with internal and external stakeholders.
• Reduce claim rejections to ensure members are not held liable for unnecessary costs.

• Build strong relationships through expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.

• Identify opportunities to enhance cost effectiveness and increase operational efficiency.
• Manage financial and other company resources under your control with due respect.
• Provide input into the risk identification processes and communicate recommendations in the appropriate forum.

• Teamwork
• Examining information (interrogate claims data)
• Articulating information
• Upholding standards
• Accountability
• Attention to detail
• Time management

Please consider your application unsuccessful if you are not contacted within two weeks of applying.

Monthly