Clinical Auditor Hospital Claims

Middlesex College; Sandton; On-site; ZAR 300 000 - 600 000; Full time

Job summary

An established industry player is seeking a Clinical Auditor to ensure proper medical treatment and billing compliance. This role involves auditing hospital claims, liaising with healthcare teams, and providing clinical expertise. You will be instrumental in protecting members' funds while ensuring efficient claims processing. If you have a nursing background and clinical auditing experience, this is a fantastic opportunity to contribute to healthcare quality and member satisfaction in a dynamic environment.

Qualifications

• 3 to 5 years of experience in clinical auditing and healthcare assessment.
• Nursing Diploma required; postgraduate qualification is a plus.

Responsibilities

• Vet hospital accounts and ensure compliance with billing guidelines.
• Daily auditing of accounts and handling queries from members and hospitals.

Skills

clinical audit

nurse

Education

Nursing Diploma as a Registered Nurse or Enrolled Nurse

Post Graduate Nursing qualification

Tools

IMED system

Job description

A well-established company is recruiting for a

CLINICAL AUDITOR: HOSPITAL CLAIMS

BRYANSTON

PURPOSE OF THE JOB

The purpose of the role is to ensure that members get proper and appropriate medical treatment in accordance with the billing guidelines, while also protecting members' funds by ensuring that there is no abuse by members or providers. Ensure that all the claims and duties are performed within the agreed service levels with providers and that claims are efficiently and accurately processed.

Duties And Responsibilities, Amongst Others Include:

• Vet hospital accounts under the guidance of the gazette
• Use clinical guidelines and protocols when vetting accounts
• Liaise with other members of the team and other departments
• Daily auditing of captured accounts
• Align hospital accounts with authorisation on system
• Checking accounts for non-chargeable items - as per gazette
• Evaluation of accounts for technical correctness using sound medical judgement
• Reconcile hospital accounts
• Deal with external auditors' queries regarding payment of hospital accounts
• Involved with mapping of new tariffs, by identifying them & sending requests to IT capturing/editing/auditing
• Provide weekly reports to management
• Investigate claims against daily reports
• Capture authorisations on the IMED system
• Handle member/hospital queries regarding hospital accounts payment
• Schedule the weekly roster for the clinical auditors
• Work with other healthcare personnel within the organisation
• Provide clinical expertise within the organisation where required
• Negotiation of discounts and credits with hospitals
• Reversal of claims and provide feedback to service providers
• Training of staff within the organisation

Qualification & Experience:

• Nursing Diploma as a Registered Nurse or Enrolled Nurse
• Post Graduate Nursing qualification would be an advantage
• 3 to 5 years (assessing experience capturing/editing/auditing)
• Previous clinical auditing experience in a managed healthcare environment is essential

Please send your CV and supporting documents to [Email Address Removed].

Desired Skills:

• clinical audit
• nurse