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