Clinical Auditor X5 (Cape Town, Johannesburg, Durban or Gqeberha)

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

As an applicant, please verify the legitimacy of this job advert on our company career page.

To ensure claims are audited timeously and accurately, with a focus on reducing wastage and abuse, and to ensure that all claims are processed in accordance with authorisations and established criteria.

• Matric/Grade 12 - Essential


• Bachelor's degree or equivalent qualification in a field such as Nursing - Essential


• Intensive Care Unit (ICU), Science in Nursing (BSN), Health Information Management (BHIM), Health Administration, Healthcare Management, or a related field - Advantageous

Experience

• 3 - 5 years of clinical experience in a healthcare environment - Essential


• Previous exposure to clinical auditing - Advantageous


• Proficiency in MS Office / Office 365 - Essential

Professional Licensing Requirements

• Registered nurse with the South African Nursing Council (SANC) - Advantageous

Knowledge

• Familiarity with medical coding systems (such as ICD-10) and accurate application for coding diagnoses, procedures, and services.


• Understanding of relevant healthcare regulations, laws, compliance requirements, and medical coding guidelines.


• Proficiency in reviewing and interpreting medical documentation, including records, notes, reports, and summaries.


• Knowledge of medical terminology, diagnoses, procedures, treatment protocols, and healthcare benefit plans.


• Understanding of billing practices, fee schedules, reimbursement methodologies, and billing guidelines.


• Knowledge of clinical auditing methodologies, including data analysis, sampling methods, and audit tools.


• Knowledge of quality assurance principles and methodologies in healthcare.


• Familiarity with healthcare information systems, claims management systems, and relevant auditing software.


• Understanding of Prescribed Minimum Benefits (PMB) legislation and its implications for healthcare coverage.


• Knowledge of Clinical Auditing, Risk Management and Clinical and Billing rules.

• Apply scheme rules, clinical policies and protocols to support funding of claims.


• Action allocated claims for audit within department KPIs and CMS requirements for claims payment.


• Ensure accurate notes are made for all journals actioned on claims audited.


• Assess PMB funding in collaboration with MCO (Managed Care Organisation) as well as approved PMB manual.


• Act as clinical support to non-clinical Claim Auditors in terms of billing rules and any other funding rules.


• Survey claims for correct application of tariff and refer discrepancies to the relevant team.


• Review retrospective claim approvals and refer for additional clinical information to Medical Advisors.


• Review claims for clinical appropriateness.


• Analyse hospital claims data and trends to identify patterns and behaviour, proactively provide feedback to the business to influence provider behaviour, and implement changes to improve claims management processes.

Client

• Build and maintain relationships with clients and internal and external stakeholders.


• Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed.


• Make recommendations to improve client service and fair treatment of clients within area of responsibility.


• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.


• Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.


• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.


• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

People

• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.


• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.


• Positively influence and manage change and offer specialist support where required.


• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.


• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.


• Take ownership for driving career development.

Finance

• Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.


• Identify solutions to enhance cost effectiveness and increase operational efficiency.


• Implement and provide input into governance processes, systems and legislation within area of specialisation.


• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes.


• Provide input into the risk identification processes development and communicate recommendations in the appropriate forum.