2 Medical Pre Authorisation jobs in South Africa

Pre Authorisation Consultant Faerie Glen

Gauteng, Gauteng Bestmed Medical Scheme

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Job Description

Bestmed Medical Scheme

Bestmed is a non-profit, mutual medical scheme registered with the Council for Medical Schemes. We have been providing healthcare to the lives of South Africans for over 60 years.

Bestmed strives to be an employer of choice by:

  1. Creating a Personally Ours culture where we can all contribute in our unique way to make Bestmed the best employer for our Talent.
  2. Creating an environment that optimizes individuals to contribute their best version of themselves.
  3. Promoting a highly engaged workforce in a performance enabling environment where employees are valued and rewarded for their commitment and dedication.

Bestmed offers an exceptional benefit programme and competitive packages, including 23 days annual leave and a workday of only 8 hours, including a 30 min break. Permanent employees have the options of life cover, disability benefits, funeral cover, pension fund, medical aid and more. Access to development opportunities are plentiful. Office benefits include free parking, free Wi-Fi, landline phone allowance, and free refreshments. Bestmed Heartbeats also have access to fitness facilities and running clubs such as an on-site gym, the Bestmed Athletics Club, Pilates and the Tempo Wellness Programme (T&C apply). Many team interactions, recognition programmes and incentives make your support structure one with lots of fun, laughter and something to strive towards. We celebrate your successes, endurances and life events with you. We constantly strive to innovate for you and by you.

If you are willing to lead the way, go the extra mile, do the right thing, be upbeat and play for the team…you may be the perfect candidate to join a journey that is Personally Yours with Bestmed!

We are committed to ensuring that all employees have opportunities for professional development, as well as fair compensation and employee benefits. We are also committed to ensuring a congenial and collegial work environment, where innovation is welcomed and encouraged. As such, we reinforce a culture of zero tolerance towards any forms of inappropriate behaviour, abuse (including abuse of power, privilege or trust), harassment, or exploitation of any kind to safeguard our members, employees and partners. This is our top priority and we take our responsibilities extremely seriously. All employees are required to share in this commitment through our Code of Conduct.

Bestmed is an equal opportunity, disability-confident employer and we are committed to achieving the highest standards of diversity, fairness and equality. We conduct the most appropriate pre-employment assessments and verification checks to ensure that high standards are maintained. Should you have a disability and require any additional support, please contact us at

Bestmed reserves the right to schedule and cancel assessments and interviews. Bestmed also reserves the right not to make a placement.

Duties & Responsibilities
  • Delivering cost-effective managed healthcare services to accomplish member satisfaction.
  • Client Relations: To assist the client by approving appropriate funding.
  • Deliver an effective call centre service in order to achieve member satisfaction.
  • Risk Management: To reduce the risk associated with hospital and authorized cases.
  • Telephone Etiquette: Answering telephone calls in a way that achieves member satisfaction.
  • Verifying prosthesis limits: To contain costs for both members and fund.
  • On-going training and development: To update knowledge and skills in order to deliver a cost-effective and professional service.
  • The actual benefit expenditure per beneficiary per month for hospitalization should be less than the budget benefit expenditure. Pre-authorization should be granted within the option benefits, Scheme and clinical protocols.
  • Effective Customer Service Delivery: To deliver an effective call centre service in order to achieve member satisfaction.
  • Delivering a cost-effective Managed Healthcare service.
Desired Experience & Qualification
  • Grade 12
  • Enrolled Nursing

Experience - Essential

  • Minimum 5 years experience as a nursing practitioner.
  • Minimum 1 year experience gained in the medical funding industry.
Interested?

Thank you for your interest in Bestmed Medical Scheme.

Due to the large amount of applications we receive, only shortlisted candidates will be contacted.

Should you not be contacted within 2 weeks of the advertisement closing date, please consider your application as unsuccessful.

Your CV will however be put onto our database and we will contact you should any suitable vacancies arise in future.

We wish you the best of luck.

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However, we have similar jobs available for you below.

Medical Claims Clinical Auditor (EE)

Eastern Cape, Eastern Cape Headhunters

Posted 15 days ago

Job Viewed

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Job Description

Reference: PE002332-RW-1

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!

Duties & Responsibilities

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.

Package & Remuneration

Monthly

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This advertiser has chosen not to accept applicants from your region.

Medical Claims Auditor Port Elizabeth

Eastern Cape, Eastern Cape Headhunters

Posted 15 days ago

Job Viewed

Tap Again To Close

Job Description

Reference: PE002332-RW-1

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!

Duties & Responsibilities

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.

Package & Remuneration

Monthly

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This advertiser has chosen not to accept applicants from your region.
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