Pre-Authorization Case Manager

SUMMARY:
Well-established company in Johannesburg North seeks a Pre-Authorization Case Manager to join their team!

POSITION INFO:
Purpose of the Role:
Responsible for managing hospital admissions telephonically, ensuring appropriate authorization, monitoring patient progress, and controlling costs according to established protocols.

Requirements:

• Qualifications: Nursing diploma (registered or enrolled nurse).
• Experience: 3-5 years of nursing experience; prior pre-authorization experience in managed healthcare is beneficial.
• Technical Knowledge: Understanding of PMB conditions, DTP care plans, hospital types, medical coding (ICD-10, CPT), and government regulations.
• Skills: Attention to detail, strong communication, teamwork, organizational skills, and computer literacy.

• Approve hospital admissions based on guidelines.
• Manage general ward and high-care cases.
• Oversee surgical and medical cases.
• Capture authorizations in the IMED system.
• Coordinate with medical advisors, hospitals, doctors, and patients.
• Provide telephonic case management and referrals for specialized cases.
• Monitor ongoing hospital cases, negotiate cost reductions, and ensure final updates.
• Handle member queries regarding hospitalization and benefits.
• Ensure compliance with service level agreements (SLA's).
• Maintain professional communication across departments.