CLINICAL HOSPITAL AUDITOR HBM

Bestmed Medical Scheme; Pretoria; Vor Ort; ZAR 480.000 - 720.000; Vollzeit

Benefits dieser Stelle

Annual leave 23 days

8-hour workday

Life cover

Medical aid

On-site gym

Wellness programme

Zusammenfassung

Bestmed Gauteng is recruiting a Clinical Hospital Auditor HBM to join the Hospital Benefit Management Department. The role focuses on auditing hospital claims and related clinical information to ensure correct funding, compliance with scheme rules and provider contracts, and efficient management of healthcare expenditure.

The successful candidate will have a nursing background with SANC registration, plus extensive experience in nursing and medical funding to support accurate audits and

Qualifikationen

• Grade 12.
• B Cur degree or Diploma in Nursing/Enrolled Nurse.
• Active SANC Membership.
• Minimum 5 years’ nursing practitioner experience.
• Minimum 2 years’ medical funding industry experience.

Aufgaben

• Audit hospital claims and related clinical information per approved authorisation.
• Verify diagnoses, treatments and outcomes are accurately recorded.
• Detect overbilling and ensure appropriate funding.
• Reimburse clients for rendered services with provided proof.
• Identify quality gaps and suggest improvements.
• Apply prosthesis limits per scheme rules and liaise with stakeholders.
• Check funding guidelines and coordinate with team as needed.

Kenntnisse

Nursing experience

Medical funding experience

SANC Registration

Auditing claims

Ausbildung

B Cur / Diploma in Nursing

Grade 12

Jobbeschreibung

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!