Nurse

Responsibilities:

• Receive and respond to enrollee and healthcare provider enquiries and calls.
• Verify enrollee eligibility, membership status and benefit entitlement.
• Review healthcare service and pre-authorisation requests within approved guidelines.
• Conduct preliminary clinical assessment of requests within professional scope.
• Issue pre-authorisation codes for approved services within delegated authority.
• Liaise with healthcare providers regarding treatment requests and required documentation.
• Provide appropriate clinical guidance to enrollees and providers within scope.
• Escalate cases requiring further clinical review or management approval.
• Handle complaints relating to healthcare access, authorisation and provider services.
• Follow up on pending authorisation requests and unresolved cases.
• Accurately document calls, clinical reviews, authorisations, complaints and resolutions.
• Maintain confidentiality of enrollee and medical information.
• Ensure compliance with HMO policies, clinical protocols, service standards and regulatory requirements.
• Collaborate with the Medical & Claims and Provider & Enrollee Management teams to resolve complex cases.

Requirements:

• A valid practising licence.

• Minimum 2 years' post-qualification nursing experience, preferably in an HMO, hospital, managed healthcare or medical insurance environment.

• Experience in healthcare pre-authorisation, utilisation review, triage or patient/customer service will be an advantage.

• Good knowledge of basic clinical assessment and healthcare services.

• Good communication and interpersonal skills.

• Ability to assess requests within approved clinical and benefit guidelines and escalate cases outside delegated authority.

• Good computer skills and ability to use healthcare/HMO management systems.

• Ability to maintain confidentiality of patient and enrollee information