Bill Auditor | Fixed Term Contract

Two (2) vacancies exist for Bill Auditors - Fixed Term Contract (6 months) based at Life Head Office in Dunkeld, reporting to the National Clinical Review Manager. The successful candidate will be responsible for managing the financial and clinical risks by reviewing claims, conducting audits of patient records and claims with regards to captured data on the LHC systems, billed items and contractual agreements. This person shall identify and highlight areas of non-compliance, manage, monitor, implement corrective action and assess the effectiveness of the corrective measures and report there on, to achieve the Life Healthcare objectives and strategy.

Critical Outputs

Management of financial risk by:

• The interpretation and application of different reimbursement contracts.
• RSRT and DRG profit/loss analysis and reporting.
• Engagement with funders regarding disputes with regards to contractual agreements.
• Analyse data trends relating to rejections and short payments etc.
• Verification of clinical coding as per policies and procedures.
• Preparing and ensuring sound audit compliances to achieve optimum business ethics.
• Participating and developing action plans within the risk management team.
• Liaison with Hospital Manco teams on funder requirements where necessary.
• Interpretation and implementation of scheme benefit rules.
• Managing risk associated with ARM/RSRT’s by developing system rules and training patient-based data.

Ensure effective and accurate billing by:

• Driving the accurate and timeous billing process to ensure Patient Services metric targets are achieved.
• Ensures accurate application and interpretation of FFS billing and Accommodation rules.
• Reporting/monitoring/assisting with of all matters relating to case management:
• Authorisation disputes
• Internal DSO
• Claim rejections
• Claim disputes/short payments
• PMB disputes.
• Repricing Errors

Management of stakeholder relationships internally and externally to promote strategy and efficiency by:

• Effective Funder liaison, facilitating operational meetings and complaints management.
• Manage Contractual obligations on SLA, TAT, ARMs.
• Develop and maintain collaborative relationships with internal stakeholders to achieve objectives.

Effective auditing of hospital operational processes:

• Evaluate data accuracy, identify deviations, implement corrective actions and monitor improvement.
• Analyse and report on trends and influence the responsible parties to drive improvements on focus areas.
• Monitor compliance to business processes and effectiveness of action plans.
• Audit the completeness and accuracy of claims e.g. Data Governance, full event details, coding, billing, etc.
• Provide support for the management of clinical updates, repricing errors and rejections.
• Ensure compliance with the clinical code of conduct to ensure the accurate interpretation of a patient event.

Effective quality management and customer care by:

• Manage Continuous Learning, Optimise performance and Promote Quality Management Systems.
• Manage Patient Experience to ensure expectations are exceeded/met.

Requirements

• Nursing Qualification, Professional Nurse with at least three years’ experience, with proven case manager and clinical coding experience of at least 3 – 5 years.
• Current SANC registration appropriate to relevant Medical Qualification.
• Knowledge of hospital patient services and billing processes and private hospital industry and practices.
• Comprehensive knowledge and understanding of CPT & ICD coding.
• Knowledge of Funder contracts, scheme rules, exclusions and benefits.
• Computer proficiency.
• Competency of related legislation e.g. National Health Act, Medical Schemes Act with regulations, Mental Healthcare Act.

Competencies

• Problem-solving, analysis and judgement.
• Attention to detail.
• Verbal and written communication skills.
• Influencing and Independence.
• Professional and technical proficiency.
• Interpersonal and relationship building skill.
• Organisational awareness.
• Excellence orientation.
• Ethical behavior/integrity.
• Resilience.

Email Careers@lifehealthcare.co.za Closing date: Friday, January 31, 2025.

Internal applicants - Before making an application, you are requested to discuss your application with your line manager. External candidates will also be considered.

Life Healthcare is an Equal Opportunity Employer.

Thank you for your interest in this opportunity. Kindly note that only shortlisted candidates will be contacted. Applicants who have not been contacted within two weeks of the closing date of this advert, should consider their application as unsuccessful.