Senior Clinical Claims Reviewer

Medihelp Medical Scheme; Pretoria; Vor Ort; ZAR 360.000 - 480.000; Vollzeit

Zusammenfassung

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

Qualifikationen

• 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.

Aufgaben

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

Kenntnisse

Communication

Negotiation

Independent work

Teamwork

Decision making

Ausbildung

Enrolled Nurse

Grade 12

Tools

Microsoft Office

Jobbeschreibung

Core Purpose

At Medihelp, we live our values daily — excellence, compassion, collaboration, and transparency — to make a real difference in the lives of our members. We’re looking for someone who lives these values through their mindset, work ethic, and interactions with others.

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

Requirements

• 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

KEY COMPETENCIES

• Excellent written and verbal communication skills
• Proficiency in Microsoft Office
• Customer-focused approach
• Strong negotiation skills
• Ability to work independently and collaboratively
• Ability to build positive working relationships
• Sound decision-making skills

Join a team where our values guide everything we do — from how we work together to how we serve our members.