CLINICAL HOSPITAL AUDITOR HBM

Bestmed Medical Scheme; Gauteng; Presencial; ZAR 350.000 - 550.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

23 days annual leave

8 hour workday (incl. 30 min lunch)

Life cover

Disability benefits

Funeral cover

Pension fund

Medical aid

Training and development opportunities

On-site gym

Wellness programme

Descripción de la vacante

Bestmed Medical Scheme in Gauteng is seeking a Clinical Hospital Auditor HBM to audit hospital claims and related clinical information, ensuring correct benefit funding and compliance with scheme rules and contracts. You will also help manage healthcare expenditure and liaise with case management for pre-authorization.

The successful candidate should have a Grade 12, a B Cur degree or Nursing Diploma, at least 5 years as a nursing practitioner, 2 years in medical funding, and active SANC

Formación

• Grade 12
• B Cur degree or Diploma in Nursing/Enrolled Nurse
• Minimum 5 years' experience as a nursing practitioner
• Minimum 2 years' experience gained in the medical funding industry
• Active SANC Membership

Responsabilidades

• Audit hospital claims and related clinical information to ensure appropriate benefit funding
• Verify that diagnoses, treatments and outcomes are clearly recorded
• Detect overbilling
• Reimburse clients for services rendered when proof is provided
• Identify gaps in quality of care and recommend improvements
• Apply prosthesis limit and reject short fall as per scheme rules
• Check funding guidelines to ensure claims are paid correctly and liaise with team members

Descripción del empleo

Bestmed Gauteng has an opportunity available for a Clinical Hospital Auditor HBM position in the Hospital Benefit Management Department.

Job purpose:

Audit hospital claims and related clinical information to ensure appropriate benefit funding, compliance with Scheme rules and provider contracts, and effective management of healthcare expenditure.

The successful candidate should have:

• Grade 12
• B Cur degree / Diploma in Nursing/Enrolled nurse
• Minimum 5 years’ experience as a nursing practitioner
• Minimum 2 years’ experience gained in the medical funding industry
• Active SANC Membership

Key responsibilities include:

• Assess and audit claims as per approved auth, liaise with case management or pre-auth.
• Verify that diagnoses, treatments, and outcomes are clearly recorded.
• Detect overbilling.
• Reimbursement clients for services that were rendered if proof was provided.
• Identify gaps in quality of care and recommend improvements.
• Apply prosthesis limit and reject short fall as per scheme rules, liaise with other stakeholders if need be.
• Check funding guidelines to make sure claims are paid correctly and liaise with team members, if needed.

Bestmed is a non-profit, mutual, self-administered medical scheme registered with the Council for Medical Schemes. We have been providing healthcare to the lives of South Africans for over 60 years. We are the largest self-administered scheme and the fourth largest open medical scheme in South Africa.

Bestmed offers an exceptional benefit programme and competitive packages, including:

• 23 days annual leave
• a workday of only 8 hours, including a 30 minute lunch break.
• Permanent employees have the options under our corporate umbrella fund, which includes life cover, disability benefits, funeral cover and pension fund.
• Permanent employees also have access to medical aid.
• Access to training and development opportunities are plentiful.
• Office benefits include, free Wi-Fi, an on-site gym, and a wellness programme.

We are committed to ensuring that all employees have opportunities for professional development, as well as fair compensation and employee benefits. We are also committed to ensuring a pleasant and mutual work environment, where innovation is welcomed and encouraged. As such, we reinforce a culture of zero tolerance towards any forms of inappropriate behaviour, abuse (including abuse of power, privilege or trust), harassment, or exploitation of any kind to safeguard our members, employees and partners. All employees are required to share in this commitment through our Code of Conduct.

Bestmed is an equal opportunity, disability-confident employer and we are committed to achieving the highest standards of diversity, fairness and equality. We conduct the most appropriate pre-employment assessments and verification checks to ensure that high standards are maintained.

Bestmed reserves the right to schedule and cancel assessments and interviews. Bestmed also reserves the right not to make a placement.

If you are willing to lead the way, go the extra mile, do the right thing, be upbeat and play for the team you may be the perfect candidate to join a journey that is Personally Yours with Bestmed!