Prospective Reviewer at WNS Global Services SA

Job Description

To ensure the accurate issuing of appropriate preauthorisations that meets the requirements of clinical appropriateness, medical necessity and clinical risk management

Qualifications

• A formal nursing qualification and registration/enrolment with SANC or a formal healthcare professional qualification( Registered / Enrolled Nurse).

Additional Information

• A minimum of 23 years experience in a general medical and general surgical ward. At least 1 of these years at a Private institution.
• Trauma/ER experience will be an advantage. Previous Managed Healthcare experience in a call centre environment will be to your advantage.

Client service delivery and quality

• Follow procedures and cooperate with peers and leader for best possible service delivery

Compliance and Risk Management

• Defined legal, statutory and regulatory compliance is maintained at the required standards
• Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary

Financial Management

• Contribute to cost savings within the department to assist with financial goals and targets

Operating Model

• Authorise hospital authorisation requests by applying coding principles, scheme rules and benefits, and managed care policies and processes  Capture accurate preauthorisation data on the system Correctly escalate complex clinical call
•  Meet delivery objectives through working with other team members  within and linked to the department / project
•  Resolve operational performance variations and problems and escalate unresolved issues to higher levels
•  Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery

Operational Implementation of Strategy

•  Keep up to date with operational changes implemented in response to important external influences
•  Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
•  Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement

Operational Leadership

• Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives
• Engage in development, coaching and mentoring
• Support transformation through valuing diversity
• Behave in alignment with the Afrocentric values

Stakeholder Management

• Educate and assist member by providing relevant clinical information to access the correct clinical benefits  Consult member's health care professional to make informed clinical decisions and manage financial risk
•  Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved
•  Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buyin

Competency Requirements:

Knowledge

• Advise on best practice health risk solutions to relevant parties
• Application of clinical intervention principles
• Understanding of Call Centre technology
• Knowledge of scheme rules and contractual negotiations
• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedures
• Knowledge and application of dispensing of meds, surgical material & procedures
• Application of financial and risk assessment methodology

Skill

• Attention to Accuracy and Detail
• Ability to negotiate and influence
• Relevant systems knowledge and application
• Problem solving and decision making skills
• Customer Focus
• Task Management
• Computer Technology Skills
• Communication Skills
• Business Writing Skills
• Numerical Ability