Specialist : Bill Review

Job Location : Gauteng, Centurion
Deadline : May 17, 2025

Key Performance Areas

Development of Bill Review Rules and Guidelines

• Provide input into the development of guidelines to review medical bills in accordance to the fee schedule and internal processing guidelines.
• Research into the RAF Serious injury, the relevant CPT and ICD codes, unit standards and cost.
• Identify all the relevant medical codes (ICD 10, CPT, Tariffs, etc) which need to be updated, within bill review scope.
• Updating the Bill Review rules in collaboration with the clinical research team.

Audit and Review Medical Bills

• Accuracy of Bill review standards on cross-walked ICD and CPT application on invoice assessments.
• Report on bill reviewed cases for the organization, and cost containment.
• Provide information relating to claims process and procedure.
• Specify and report on manual bill review and later automated bill reviewed cases.
• Support in the identification, development and implementation of cost-effective processes in order to increase efficiency and reduce cost drivers related to the area of specialization.
• Participate in the development of basket of care and its alternatives for each individual treatment plans / protocols.
• Provide inputs to development of treatment plans / protocols and crosswalks.
• Identify relevant treatment plans and gaps in bill review and provide the feedback to Senior Medical Manager to update treatment protocols.

Policy Review and Implementation

• Contribute to the development and implementation of developmental policy, procedures and processes.
• Keep up to date with effective SOP’s, policy and practice execution strategies.

Reporting

• Prepare and submit regulation reports as and when required to provide progress updates and / or inform management decisions.
• Develop reports / procedures and guide the process through the alignment of the documents to the overall RAF’s Strategy.
• Develop functional reporting systems, for management, projects or performance reporting.

Provide Support to Bill Reviewers

• Provide bill review clinical and technical support.
• In collaboration with L&D, ensure updated and standardised training of Bill Reviewers.
• Support the bill review team in complicated queries.
• Manage and create productivity management tool for bill reviewers.
• Develop quality management tool / sampling tool to monitor work of bill reviewers.

Stakeholder Management

• Facilitate and manage communication with relevant internal and external stakeholders in relation to investments and proactively and progressively manage the relationships.
• Manage relationships with vendors, service providers or procurement teams and ensure that all relevant procured items are invoiced and paid on time.

Qualifications and Experience

• Bachelor’s Degree / Advanced Diploma in Nursing related qualification.
• Valid Registration with the SANC as a Registered Nurse.
• Qualification in Critical care / Emergency care / Theatre technique will be advantageous.
• Relevant 5 - 7 years’ experience in an ICU Unit / High Care / Emergency Unit of a multidisciplinary hospital or Medical Scheme environment.
• With experience in working with ICD 10 codes, CPT codes, NAPPI codes, tariffs, and all modalities of treatment in ICU, theatre, and ward.