Clinical Auditor MMH261021-3

Momentum; Sandton; On-site; ZAR 900,000 - 1,300,000; Full time

Job summary

Momentum is seeking an experienced hospital claims auditor to review clinical appropriateness, treatment, and billing consistency, focusing on fraud detection and cost containment. You will apply clinical policies to determine claim eligibility and update auditing rules to reflect regulatory changes.

Collaborating with medical advisors and network teams, you will analyze trends, share findings, and propose process improvements to enhance service quality and compliance within healthcare benefits.

Qualifications

• Bachelor's degree or equivalent in a healthcare-related field.
• 6–10 years clinical experience in a healthcare environment.

Responsibilities

• Review hospital claims for clinical appropriateness and billing consistency, identifying potential fraud or errors.
• Apply scheme rules and policies to determine claim eligibility and accuracy.
• Update clinical auditing rules (CARM) to stay current with industry and regulatory changes.
• Review hospital network billing guidelines annually and suggest cost-saving improvements.

Skills

Clinical auditing

Fraud detection

Data analysis

Education

Bachelor's degree in healthcare or related field

Job description

Role Purpose

Conduct timely and accurate audits of hospital claims, focusing on customer centricity and maintaining the quality of service rendered to scheme members within the benefit design.

Requirements

• Bachelor's degree or equivalent qualification in a field such as Theatre Technique, Intensive Care Unit (ICU), Science in Nursing (BSN), Health Information Management (BHIM), Health Administration, Healthcare Management, or a related field
• 6-10 years clinical experience in a healthcare environment (i.e., insurance/healthcare organisation/healthcare consulting firm)
• 2-3 years claims audit/review experience

Duties and Responsibilities

PROCESS

• Review specific hospital claims for clinical appropriateness, treatment received, over usage of equipment/materials, and consistency with billing rules, with a focus on identifying potential fraudulent activities or billing errors.
• Apply scheme rules, clinical policies, and protocols to ensure compliance and accurate determination of claim eligibility and appropriateness.
• Conduct regular reviews and updates of clinical auditing rules (CARM) to ensure relevance, accuracy, and alignment with industry trends and regulatory changes.
• Review hospital network billing guidelines annually and provide feedback to the business for improvements, while actively seeking opportunities for cost savings and process efficiencies.
• 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

• Liaise with the medical advisor when needed to address complex cases or obtain specialised clinical expertise, ensuring accurate assessment and appropriate resolution.
• Provide clinical support to the provider network team, discussing identified trends, patterns, and potential areas for improvement to enhance service quality and compliance.

PEOPLE

• Attend quarterly operational meetings, provide feedback on trends, and discuss the application of billing guidelines, while actively participating in internal and external training programs to enhance knowledge and skills related to clinical auditing techniques, fraud prevention, and industry advancements.
• Act as a subject matter expert and resource for colleagues, providing guidance, training, and support to enhance the overall knowledge and competency of the clinical auditing team.
• Commitment to ongoing learning and staying updated with industry trends, best practices, and regulatory changes in healthcare, clinical auditing, and relevant areas.

FINANCE

• Ensure accurate recording of savings according to pay codes and reason codes, contributing to financial tracking and reporting processes, with a focus on identifying opportunities for cost savings and process efficiencies.
• Collaborate with IT teams to optimise and leverage data analytics tools and systems to enhance audit processes, identify patterns, and develop proactive strategies for risk assessment, fraud detection, and cost containment.