Nurse – Enrollee & Provider Services

About the role

The role involves providing clinical support to enrollees and healthcare providers within an HMO environment. You will assess eligibility, authorise services, and ensure compliance with policies while maintaining confidentiality of patient information.

Key responsibilities

• Receive and respond to enrollee and provider enquiries, verifying eligibility and benefit entitlement.
• Review healthcare service and pre‑authorisation requests against approved guidelines.
• Conduct preliminary clinical assessments and issue pre‑authorisation codes within delegated authority.
• Liaise with providers regarding treatment requests, required documentation, and clinical guidance.
• Escalate cases that need further clinical review or management approval.
• Handle complaints related to healthcare access, authorisation, and provider services.
• Follow up on pending authorisations and unresolved cases, documenting all interactions accurately.
• Maintain confidentiality of enrollee and medical information and ensure compliance with HMO policies and regulatory requirements.

Required profile

• A valid practising nursing licence.
• Minimum 2 years post‑qualification nursing experience, preferably in an HMO, hospital, managed‑healthcare or medical‑insurance setting.
• Experience with pre‑authorisation, utilisation review, triage or patient/customer service is an advantage.
• Good knowledge of basic clinical assessment and healthcare services.
• Strong communication and interpersonal skills.
• Ability to assess requests within clinical and benefit guidelines and to escalate when necessary.
• Proficiency with computers and healthcare/HMO management systems.
• Commitment to maintaining confidentiality of patient and enrollee information.

Required skills

• Clinical assessment
• Healthcare/HMO management systems