Pre-Authorization Case Manager

Recruiter:

Fusion Personnel

Job Ref:

JHB005284/Maris

Date posted:

Saturday, February 15, 2025

Location:

Johannesburg, South Africa

Salary:

450000 Annually

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.

Key Responsibilities:

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.

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