Overview
Clinical Auditor Hospital Claims Jobs in Sandton, South Africa at Middlesex College
A well-established company is recruiting for a
CLINICAL AUDITOR: HOSPITAL CLAIMS
BRYANSTON
PURPOSE OF THE JOB
The purpose of the role is to ensure that members get proper and appropriate medical treatment in accordance with the billing guidelines, while also protecting members’ funds by ensuring that there is no abuse by members or providers. Ensure that all the claims and duties are performed within the agreed service levels with providers and that claims are efficiently and accurately processed.
Duties And Responsibilities, Amongst Others Include:
Vet hospital accounts under the guidance of the gazette
Use clinical guidelines and protocols when vetting accounts
Liaise with other members of the team and other departments
Daily auditing of captured accounts
Align hospital accounts with authorisation on system
Checking accounts for non-chargeable items – as per gazette
Evaluation of accounts for technical correctness using sound medical judgement
Reconcile hospital accounts
Deal with external auditors’ queries regarding payment of hospital accounts
Involved with mapping of new tariffs, by identifying them & sending requests to IT capturing/editing/auditing
Provide weekly reports to management
Investigate claims against daily reports
Capture authorisations on the IMED system
Handle member/hospital queries regarding hospital accounts payment
Schedule the weekly roster for the clinical auditors
Work with other healthcare personnel within the organisation
Provide clinical expertise within the organisation where required
Negotiation of discounts and credits with hospitals
Reversal of claims and provide feedback to service providers
Training of staff within the organisation
Qualification & Experience:
Nursing Diploma as a Registered Nurse or Enrolled Nurse
Post Graduate Nursing qualification would be an advantage
3 to 5 years (assessing experience capturing/editing/auditing)
Previous clinical auditing experience in a managed healthcare environment is essential
Please send your CV and supporting documents to [Email Address Removed].
Desired Skills:
Clinical audit
Nurse
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Title: Clinical Auditor Hospital Claims
Company: Middlesex College
Location: Sandton, South Africa
Category: Healthcare (Healthcare Compliance)
