Talent Pool: Clinical Auditor MMH251111-2

Role PurposeThe purpose of this role is to conduct timely and accurate audits of hospital claims, focusing on customer centricity and maintaining the quality of service rendered to scheme members within the benefit design.RequirementsQualification & ExperienceRegistered Nurse / Allied Health Professional is essentialRegistered Nurse with the South African Nursing Council (SANC) is essentialCoding certification (ICD-10, CPT, DRG) - advantageousMinimum of 5 years working experience within managed care industry KnowledgeFamiliarity with medical coding systems (such as ICD-10) and accurate application for coding diagnoses, procedures, and services.Understanding of relevant healthcare regulations, laws, compliance requirements, and medical coding guidelines.Proficiency in reviewing and interpreting medical documentation, including records, notes, reports, and summaries.Knowledge of medical terminology, diagnoses, procedures, treatment protocols, and healthcare benefit plans.Understanding of billing practices, fee schedules, reimbursement methodologies, and hospital billing guidelines.Knowledge of clinical auditing methodologies, including data analysis, sampling methods, and audit tools.Knowledge of quality assurance principles and methodologies in healthcare.Familiarity with healthcare information systems, electronic health records (EHRs), claims management systems, and relevant auditing software.Understanding of Prescribed Minimum Benefits (PMB) legislation and its implications for healthcare coverage.Oracle system knowledge or familiarity with other claims management software.Knowledge of Clinical Auditing and Risk Management (CARM) rules.Duties and ResponsibilitiesPROCESSReview specific hospital claims for clinical appropriateness, treatment received, over usage of equipment/materials, and consistency with billing rules, with a focus on identifying potential fraudulent activities or billing errors.Apply scheme rules, clinical policies, and protocols to ensure compliance and accurate determination of claim eligibility and appropriateness.Conduct regular reviews and updates of clinical auditing rules (CARM) to ensure relevance, accuracy, and alignment with industry trends and regulatory changes.Review hospital network billing guidelines annually and provide feedback to the business for improvements, while actively seeking opportunities for cost savings and process efficiencies.Analyse hospital claims data and trends to identify patterns and behaviour, proactively provide feedback to the business to influence provider behaviour, and implement changes to improve claims management processes.CLIENTLiaise with the medical advisor when needed to address complex cases or obtain specialised clinical expertise, ensuring accurate assessment and appropriate resolution.Provide clinical support to the provider network team, discussing identified trends, patterns, and potential areas for improvement to enhance service quality and compliance.PEOPLEAttend quarterly operational meetings, provide feedback on trends, and discuss the application of billing guidelines, while actively participating in internal and external training programs to enhance knowledge and skills related to clinical auditing techniques, fraud prevention, and industry advancements.Act as a subject matter expert and resource for colleagues, providing guidance, training, and support to enhance the overall knowledge and competency of the clinical auditing team.Commitment to ongoing learning and staying updated with industry trends, best practices, and regulatory changes in healthcare, clinical auditing, and relevant areas.FINANCEEnsure accurate recording of savings according to pay codes and reason codes, contributing to financial tracking and reporting processes, with a focus on identifying opportunities for cost savings and process efficiencies.Collaborate with IT teams to optimise and leverage data analytics tools and systems to enhance audit processes, identify patterns, and develop proactive strategies for risk assessment, fraud detection, and cost containment.-346021296