Clinical Auditor

Recruiter:

Hire Power

Job Ref:

PE000217/JD

Date posted:

Wednesday, September 4, 2024

Location:

Portelizabeth, South Africa

SUMMARY:

A permanent, full-time opportunity exists for a Professional Nurse: Clinical Auditor, at its office in Port Elizabeth. Reporting to the Team Leader, your primary role is to ensure hospital claims are audited timeously and accurately with a focus on reducing wastage and abuse, as well as ensuring that claims are processed according to authorisations.

REQUIREMENTS

A National Senior Certificate is essential
It is essential to have a Nursing Diploma or Degree
The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse
MS Office / Office 365 proficiency
Minimum of 2 years of private hospital nursing experience
Previous exposure to clinical auditing is highly advantageous
SA citizen with a clean criminal history is essential

DUTIES AND RESPONSIBILITIES:

INTERNAL PROCESS

Apply scheme rules, clinical policies and protocols to funding.
Action allocated hospital 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 prosthesis for PMB funding when benefits are exceeded or if there is no benefit.
Ensure accurate completion of authorisations on claim finalisation.
Refer LOC/ LOS / item or drug approval queries to case managers for resolution.
Act as clinical support to non-clinical hospital claim auditors in terms of hospital tariff applications and clinical guidance (e.g. procedures, devices & drug utilisation).
Survey claims for correct application of tariff and refer discrepancies to the relevant team.
Review retrospective claim approvals and send journal instructions for additional payments to the relevant team.
Review hospital claims for clinical appropriateness, treatment authorised, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.

CUSTOMER SERVICE

Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timely feedback.
Escalate queries to the relevant team or stakeholder.
Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
Resolve claim queries accurately and timeously.
Build and maintain relationships with internal and external stakeholders.
Reduce claim rejections to ensure members are not held liable for unnecessary costs.

PEOPLE

Build strong relationships through expressing positive expectations.
Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
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.

FINANCE

Identify opportunities to enhance cost-effectiveness and increase operational efficiency.
Manage financial and other company resources under your control with due respect.
Provide input into the risk identification processes and communicate recommendations in the appropriate forum.

COMPETENCIES:

Teamwork
Examining information (interrogate claims data)
Articulating information
Upholding standards
Accountability
Attention to detail
Time management

Location: Port Elizabeth. 100% on site
Career level: 2-4 years
Industry: Healthcare
Salary: Commensurate with experience. The package includes compulsory medical aid and a provident fund.
Working hours: Monday to Friday 09h00 to 16h30 (no weekend work or overtime)

Notes:
Short-listed candidates may be expected to complete and pass assessments before moving to the next stage of the recruitment process.
Should you not be contacted within two weeks, please consider your application unsuccessful.

POSITION INFO:
Professional Nurse: Clinical Auditor

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