Clinical Auditor : Hospital Claims

We are thrilled to present an exciting opportunity with our client in the Medical Aid Scheme industry for a Registered Nurse Clinical Auditor: Hospital Claims. If you're looking to join a dynamic team where your expertise can make a real impact, this role is for you. If you’re ready to take on this exciting challenge and make a difference in the medical aid scheme sector, we want to hear from you! Join a team that values clinical excellence and service integrity. Apply now!

Key Performance Areas (KPAs):

1. Ensure proper and appropriate medical treatment for members, safeguarding their funds while ensuring there’s no abuse by members or providers.
2. Efficiently process claims within agreed service levels, ensuring accuracy and compliance with billing guidelines.

Job Key Responsibilities:

1. Vet hospital accounts according to the gazette guidelines.
2. Use clinical guidelines and protocols when reviewing accounts.
3. Liaise with teams and departments to ensure smooth processes.
4. Audit captured accounts daily for accuracy.
5. Align hospital accounts with system authorisations.
6. Check for non-chargeable items as per gazette regulations.
7. Evaluate accounts for technical correctness, using medical judgement.
8. Reconcile hospital accounts efficiently.
9. Respond to external auditors’ queries regarding account payments.
10. Assist with mapping new tariffs, identifying and requesting them from IT.
11. Provide weekly reports to management.
12. Investigate claims based on daily reports.
13. Capture authorisations on the IMED system.
14. Handle member and hospital queries regarding account payments.
15. Schedule weekly roster for clinical auditors.
16. Negotiate discounts and credits with hospitals.
17. Oversee the reversal of claims and provide feedback to service providers.