Clinical Review Nurse - L1

SUMMARY:

Our client, a company who aims to bridge the gap between digital expectations and real outcomes for various companies with Digital Intelligence, seek to employ Clinical Review Nurses at their offices in the CBD of Cape Town.

POSITION INFO:

FUNCTION

Note: (*) denotes essential functions

• Member Identification
• Performs intake of calls from members or providers regarding services via telephone, fax, EDI (*)
• Research and enter member information (*)
• Screens requests for appropriate referral to medical services staff (*)
• Approve services that do not require a medical review in accordance with the benefit plan (*)
• Performs non-medical research including eligibility verification, COB, and benefits verification (*)
• Documentation and Communication
• Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements (*)
• Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g. Claim Administrators, Plan Sponsors, and 3rd party payers as well as Member, Family, and Healthcare Team Members respectively)
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality (*)
• Communicate with Aetna Case Managers, when processing transactions for members active in this Program (*)
• Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures (*)
• Sedentary work involving significant periods of sitting, talking, hearing and keying.
• Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor.
• Working environment includes typical office conditions.

EDUCATION REQUIREMENTS

• S. Nursing Graduate
• SA Registered Nurse

WORK EXPERIENCE REQUIREMENTS

• SA Registered Nurse with 1-2 years clinical experience
• 1+ years of Call Centre Experience (Preferred)

Should you meet all the requirements and wish to apply for this role, please send your latest CV and motivation to --------Please upload your CV here-------->

 

NB! This job is now closed. You can apply for other jobs by uploading your CV.

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