Medical Claims Clinical Auditor (EE)
Headhunters
- Eastern Cape
- Permanent
- Full-time
- A National Senior Certificate is essential.
- It is essential to have a Nursing Diploma or Degree.
- The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse.
- MS Office / Office 365 proficiency.
- Minimum of 2 years’ private hospital nursing experience.
- Previous exposure to clinical auditing is highly advantageous.
- Be available to work at one of our offices based in Richmond Hill (Gqeberha), Cornubia (Durban), Bellville (Cape Town) or Centurion
INTERNAL PROCESS
- Apply scheme rules, clinical policies and protocols to funding.
- Action allocated hospital claims for audit within department KPIs and CMS requirements for claims payment.
- Ensure accurate notes are made for all journals actioned on claims audited.
- Assess prosthesis for PMB funding when benefits are exceeded or if there is no benefit.
- Ensure accurate completion of authorizations on claim finalization.
- Refer LOC/ LOS / item or drug approval queries to case managers for resolution.
- Act as clinical support to non-clinical hospital claim auditors in terms of hospital tariff applications and clinical guidance (e.g. procedures, devices and drug utilization).
- Survey claims for correct application of tariff and refer discrepancies to the relevant team.
- Review retrospective claim approvals and send journal instructions for additional payments to the relevant team.
- Review hospital claims for clinical appropriateness, treatment authorized, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.
- Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timeous feedback.
- Escalate queries to the relevant team or stakeholder.
- Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
- Resolve claim queries accurately and timeously.
- Build and maintain relationships with internal and external stakeholders.
- Reduce claim rejections to ensure members are not held liable for unnecessary costs.
- Build strong relationships through expressing positive expectations.
- Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.
- Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
- Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
- Identify opportunities to enhance cost effectiveness and increase operational efficiency.
- Manage financial and other company resources under your control with due respect.
- Provide input into the risk identification processes and communicate recommendations in the appropriate forum.
- Teamwork
- Examining information (interrogate claims data)
- Articulating information
- Upholding standards
- Accountability
- Attention to detail
- Time management
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