Senior Clinical Claims Auditor: Hospital & Wound Care

Medihelp Medical Scheme; Pretoria; On-site; ZAR 360,000 - 480,000; Full time

Job summary

Medihelp Medical Scheme is seeking a Senior Clinical Claims Reviewer to audit hospital, private nursing, and wound care claims using in-depth knowledge of hospital contracts and negotiated tariff structures. The role emphasizes accuracy, regulatory understanding, and collaborative problem-solving within a managed care environment.

Ideal candidates will bring strong communication, negotiation, and independent working skills, with a track record in clinical account review and familiarity with

Qualifications

• Grade 12 and an Enrolled Nurse or Nursing Assistant qualification.
• Current registration with the SANC.
• At least two years’ experience in clinical account review and auditing, preferably in a hospital or managed care environment.
• Comprehensive knowledge of the Medical Scheme Act, with sound knowledge of ICD-10, CPT-4 & RPL codes.
• Knowledge of the Scheme Rules, Scheme Tariffs and exclusions.

Responsibilities

• The Senior Clinical Claims Reviewer primarily audits hospital, private nursing, and wound care claims using knowledge of hospital contracts and negotiated tariff structures.

Skills

Communication

Negotiation

Independent work

Teamwork

Decision making

Education

Enrolled Nurse

Grade 12

Tools

Microsoft Office

Job description

Medihelp Medical Scheme is seeking a Senior Clinical Claims Reviewer to audit hospital, private nursing, and wound care claims using in-depth knowledge of hospital contracts and negotiated tariff structures. The role emphasizes accuracy, regulatory understanding, and collaborative problem-solving within a managed care environment.

Ideal candidates will bring strong communication, negotiation, and independent working skills, with a track record in clinical account review and familiarity with