Pre-Auth Nurse

Key Performance Areas/Key Result Areas

• Validation of membership and benefits based on plan type

• Application of policy terms and condition, including waiting periods, exclusions and correct assessment of continuation of benefits and applicable cover limits

• Utilisation of network providers and appropriate facility, e.g. day clinic for day procedures

• Processing of upfront payment requests

• Maintain service SLA (Call, PCM. What’s up and emails)

• Adhere and comply to Company policies and Regulator requirements

Key Tasks

Pre-auth process

• Prioritize incoming authorization requests and/or queries according to urgency.

• Provide correct applicable information in respect of policy terms and conditions, benefits and preferred providers/ facilities in respect of all services requiring to patients or service providers.

• Assess pre-authorisation requests for GP visits, specialist visits, emergency room visits, diagnostic procedures, hospitalisation for illness and accident events, including the appropriate facilities (Day clinics, Sub-Acute facilities, home nursing and preferred providers)

• Confirm membership status & available benefits on the system and request applicable documentation (e.g. billing history, motivational letter or accident report) before a final assessment to approve or decline can be made

• Exclude possible non-disclosure of pre-existing conditions

• To check the reasons for authorisation and documentation received are appropriate and confirm if it is according to set protocols, guidelines, formularies and preferred provider agreements. Based on protocols approve or decline. If the reason for authorisation is not defined in the protocols or guidelines escalate the case for clinical review.

• Approve or decline benefits accurately according to the benefits per benefit option and strictly according to the protocols

• Provide members and applicable provider(s) with verbal and/or written notification with regards to the outcome of the pre-authorisation request.

• Handle and escalate appeals on decline authorisation requests and complaints to the clinical review team

• Process upfront payment request according to protocol and indicate the payment date based on admission date to determine the urgency of the payment

• Appropriate referral to case management team

General

• Adhere to all verbal or written instructions and comply with Company policies and Regulator requirements

• Accurate and complete capturing of all relevant information as well as approved documents on the appropriate operational systems

• Utilise the SRM system to obtain all documents before sending to clients to ensure latest updated documents is used

• Comply with LMS training deadlines and pass rates

• Maintain confidentiality and do security checks before information is disclosed to clients

• Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems

• Adhere and maintain set turnaround times:

• Answering Calls Within 10 seconds

• Responding to a WhatsApp Within 2 minutes

• Responding to a Please Call Me Within 2 minutes

• Responding to Emails Within 5 minutes

• Providing an Auth -Unplanned Within 20 minutes

• Providing an Auth -Planned Within 48hrs to 2 weeks before procedure/admission

• Providing a Repudiation Letter Within 24 hours – in writing

• Providing Repudiation feedback Verbally- within 20 minutes after the

outcome is confirmed

• Responding to Internal Emails Within 1 working day

• Responding to Escalations Within 1hour

• Responding to Abandoned Calls To be contacted within 1 hour of being sent out

• Feedback on Authorisation request Within 24hours

• Feedback on Case Management Within 8 hours