Senior Clinical Claims Auditor (Nursing)

Bestmed Medical Scheme; Pretoria; On-site; ZAR 480,000 - 720,000; Full time

Benefits offered by this job

Annual leave 23 days

8-hour workday

Life cover

Medical aid

On-site gym

Wellness programme

Job summary

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

Qualifications

• 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.

Responsibilities

• 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.

Skills

Nursing experience

Medical funding experience

SANC Registration

Auditing claims

Education

B Cur / Diploma in Nursing

Grade 12

Job description

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