Clinical Claims Auditor & Analytics Lead

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

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.