Pre-Auth Agent | Affinity Health

Affinity Health Job Vacancies – Pre-Auth Agent

Join Our Exclusive Talent Pool! We believe in nurturing talent and providing a platform for growth. As we expand our horizons, we are building a talent pool of passionate professionals who share our commitment to excellence. A growing Company situated in Benoni is seeking a Pre-Auth Agent to facilitate the pre-authorization process as requested by members or service providers in an efficient, equitable, and client-centered manner.

Key Performance Areas

• Pre-Auth Process
• General

Key Tasks

Pre-auth Process:

• Conduct bi-daily checks and maintain continuous record-keeping to ensure all unanswered PCM and phone calls are returned within SLA.
• Prioritize incoming authorization requests and queries based on urgency.
• Provide accurate information regarding policy terms and conditions, benefits, and preferred providers/facilities.
• Assess and authorize or decline pre-authorization requests for various medical visits and emergencies based on benefits and policy rules.
• Escalate complex pre-authorization requests to the appropriate authority for final approval.
• Assist in follow-up on outstanding information related to pre-authorization requests.
• Direct members to preferred/network providers and assist in obtaining necessary information.
• Confirm membership status and available benefits, and request applicable documentation.
• Escalate possible non-disclosure of pre-existing conditions and ensure compliance with protocols and guidelines.
• Approve or decline benefits accurately according to protocols.
• Provide verbal and/or written notification to members and providers regarding the outcome of pre-authorization requests.
• Handle and escalate appeals and complaints as necessary.
• Process upfront payment requests according to protocol.
• Ensure appropriate referrals to pre-auth agents and case management team.

General:

• Adhere to Company policies and Regulator requirements.
• Accurately capture all relevant information and approved documents on operational systems.
• Utilize the SRM system to obtain updated documents.
• Comply with training deadlines and maintain confidentiality.
• Stay updated on scheme rules, legislation, protocols, and systems.
• Adhere to set turnaround times for various tasks.

Other Requirements

• Ability to work shifts.
• Day/night shifts as scheduled.

Essential Qualifications

• Matric.
• Experience in health and customer care industry.

Essential Experience

• Clinical Experience.
• Healthcare industry experience.
• Experience with Computer Aided Dispatch System.
• Managed Healthcare experience.

Knowledge and Skills

• Administration Skills.
• Exceptional Communication Skills.
• Organizing and Time-management skills.
• Computer literacy.
• Knowledge of medical and emergency care terminology.
• Problem-solving skills.

Attributes

• Compassionate.
• Calm.
• Professional.
• Strong attention to detail.
• Honest, hardworking, and humble.