Professional Nurse : Clinical Auditor

Headhunters; Gqeberha; On-site; ZAR 300,000 - 450,000; Full time

Job summary

A leading company in the Insurance Industry is seeking a Professional Nurse: Clinical Auditor in Port Elizabeth. The role involves auditing hospital claims, ensuring compliance with clinical policies, and providing excellent customer service to stakeholders. Candidates should have a Nursing Diploma, SANC registration, and at least 2 years of experience in private hospital nursing.

Qualifications

• At least 2 years’ private hospital nursing experience.
• Experience in clinical auditing.

Responsibilities

• Auditing hospital claims within departmental KPIs and CMS requirements.
• Investigating claim queries and providing timely feedback.
• Identifying opportunities for cost efficiency.

Skills

Articulating information

Upholding standards

Time management

Education

National Senior Certificate

Nursing Diploma or Degree

SANC registration as a Registered Nurse

Job description

Our client in the Insurance Industry is currently seeking a Professional Nurse: Clinical Auditor in Port Elizabeth.

The role involves ensuring hospital claims are audited promptly and accurately to reduce wastage and abuse, and to ensure claims are processed according to authorisations.

Requirements:

1. A National Senior Certificate.
2. A Nursing Diploma or Degree.
3. Registration with the South African Nursing Council (SANC) as a Registered Nurse.
4. At least 2 years’ private hospital nursing experience.
5. Experience in clinical auditing.
6. Skills in articulating information, upholding standards, and time management.

Responsibilities include:

1. Applying scheme rules, clinical policies, and protocols to funding.
2. Auditing hospital claims within departmental KPIs and CMS requirements.
3. Making accurate notes for all claims audited.
4. Assessing prosthesis for PMB funding and benefits.
5. Completing authorisations on claim finalisation accurately.
6. Referring queries to case managers.
7. Supporting non-clinical auditors with clinical guidance.
8. Surveying claims for correct tariff application and addressing discrepancies.
9. Reviewing retrospective claims and instructing additional payments.
10. Reviewing claims for clinical appropriateness and billing rules compliance.

Customer Service:

1. Investigating claim queries and providing timely feedback.
2. Escalating issues as needed.
3. Providing accurate information and advice to stakeholders.
4. Building relationships with stakeholders.
5. Reducing claim rejections to avoid unnecessary costs for members.

People Development:

1. Building strong relationships and expressing positive expectations.
2. Continuously developing industry and subject matter expertise.
3. Contributing to innovation and sharing ideas.
4. Participating in a culture of productivity and quality.

Financial Management:

1. Identifying opportunities for cost efficiency.
2. Managing resources responsibly.
3. Contributing to risk management processes.