Clinical Auditor - Durban at Momentum Metropolitan Holdings Limited

Role Purpose    

• Ensuring hospital claims are audited timeously and accurately as per our service level agreement, focusing on customer centricity and the quality of service rendered to the member within the scheme's benefit design.

Requirements    
WHAT YOU'LL NEED:

• Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife).
• Current registration with the SANC, on application.
• Diploma in Theatre Technique or ICU (or minimum 3 years relevant experience)
• RPL course would be an advantage
• At least 5 years post graduate clinical experience
• At least 3 years Managed Care/Medical Aid industry experience  
• Strong knowledge of PMB legislation, Clinical Coding (ICD 10 , CPT & NHRPL), hospital and doctor’s billing guidelines  is highly advantageous
• Strong Oracle system knowledge and CARM rules is an advantage

Duties & Responsibilities    
WHAT YOU'RE GOING TO DO

• Review specific hospital claims for clinically appropriateness, treatment received, over usage of equipment / materials and consistency with billing rules;
• Apply scheme rules, clinical policies and protocols;
• Liaise with the medical advisor if necessary;
• Review and maintain clinical auditing rules (CARM) annually;
• Review hospital network billing guidelines annually and feedback to the business;
• To identify hospital trends and claiming patterns with the objective of changing provider behaviour and giving continuous feedback to the business;
• Clinical support to provider network team and discussing identified trends to provider team;
• Attend quarterly HRM operational meetings and feedback regarding trends and application of billing guidelines;
• Action clinical auditing work and volumes timeously and within set service level agreement;
• Assist with auth-claim matching queries
• Ensure accurate savings is recorded according to pay codes and reason codes; reviewing automated monthly savings report;

Competencies    
WHAT COMPETENCIES YOU'LL REQUIRE

• Excellent problem solving skills
• Accurate and vigilant
• Target oriented
• Ability to work under pressure and meet deadlines
• Analytical thinking and investigative mind
• Conceptual thinking
• Attention to Details
• Self-Motivation
• Teamwork focused
• Analytical Thinking
• Good time management skills
• Quality orientated
• Trend management focus
• The ability to apply, maintain and expand professional and technical knowledge in order to deliver a better service to customers and improve performance, including sharing knowledge and experience with others
• Excellent verbal Communication