Senior Clinical Claims Reviewer

MediHelp; South Africa; On-site; ZAR 400,000 - 650,000; Full time

Job summary

Medihelp is seeking a Senior Clinical Claims Reviewer to audit hospital, private nursing, and wound care claims using knowledge of negotiated tariffs and hospital contracts. You will ensure accurate adjudication in line with the Medical Scheme Act.

The role requires Grade 12 plus Enrolled Nurse or Nursing Assistant, SANC registration, and at least two years in clinical account review. Strong communication and collaboration are essential.

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.
• 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

• Audit hospital, private nursing, and wound care claims using hospital contracts and negotiated tariff structures.
• Ensure accurate adjudication of clinical claims in line with Medical Scheme Act.
• Collaborate with teams to resolve billing disputes and improve processes.

Skills

Communication

Negotiation

Independent and collaborative work

Customer-focused approach

Strong decision-making

Education

Grade 12

Enrolled Nurse or Nursing Assistant qualification

SANC registration

Tools

Microsoft Office

Job description

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.

Senior Clinical Claims Reviewer Responsibilities

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.