Affinity Health Vacancies | Nurse
Job Location: Gauteng
Job Sector: Healthcare
Job Type: Permanent
Job Salary: R30 000.00 – R35 000.00 Per Month
Preauthorisation Nurse
Affinity Health
Affinity Health is seeking experienced Preauthorisation Nurses to join our team in Benoni. This role involves evaluating the legitimacy of medical service or treatment requests from members or providers, ensuring timely, client-centered decisions aligned with set protocols.
Key Responsibilities
Authorise or Decline Medical Services/Treatment
• Validate member eligibility, benefits, and plan coverage.
• Confirm compliance with policies, exclusions, waiting periods, and benefit limits.
• Approve or decline requests per protocols and benefit guidelines.
• Conduct security checks before sharing information.
• Refer cases to the clinical review team as needed.
Mitigate Waste or Abuse of Benefits
• Assess preauthorisations for GP/specialist visits, ER care, diagnostics, and hospitalizations.
• Request medical documentation (e.g., history, accident reports) to finalize decisions.
• Verify continuation of benefits and coverage limits.
• Identify non-disclosed pre-existing conditions.
• Ensure requests align with guidelines, formularies, and provider agreements.
• Promote cost-effective network providers and alternative facilities (e.g., day clinics, home nursing).
• Escalate cases requiring clinical review.
• Advise members/providers on policy terms, benefits, and preferred providers.
• Stay updated on scheme rules, legislation, and system changes.
Administrative Duties
• Prioritize urgent authorization requests and queries.
• Process upfront payments per protocols and assess urgency.
• Accurately capture data on operational systems.
• Communicate authorization outcomes to members/providers verbally/written.
• Handle appeals and complaints, escalating when necessary.
• Use the Intranet for updated documents and maintain confidentiality.
• Adhere to policies, SLAs, turnaround times, and QA standards.
Candidate Requirements
Essential Experience
• Managed Healthcare in a Contact Center environment.
• Theatre or ICU experience.
Essential Qualifications
• Matric certificate.
• Nursing Diploma/Degree (Registered Nurse).
Legal Requirements
• Valid SANC registration.
Other
• Fluency in Afrikaans (written and spoken).
Knowledge and Skills
• Proficient in MS Office.
• Strong administrative skills.
• Understanding of ICD, BHF, and CPT codes.
Attributes
• Professional, flexible, and detail-oriented.
• Accountable, honest, hardworking, and humble.
Please note: Applications not responded to within two weeks will be considered unsuccessful.