Clinical Auditor at Momentum Metropolitan Holdings Limited

Requirements

• Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife) is essential
• Current registration with the SANC, on application
• Diploma in Theatre Technique or ICU (or minimum 3 years relevant experience) is essential.
• RPL course would be an advantage
• At least 5 years of post-graduate clinical experience is essential.
• At least 3 years of Managed Care/Medical Aid industry experience is essential.
• Strong knowledge of PMB legislation, Clinical Coding (ICD10, CPT & NHRPL), hospital anddoctor's billing guidelines ishighly advantageous.
• Strong Oracle system knowledgeand CARM rules is an advantage

Duties & Responsibilities

• Review specific hospital claimsfor clinical appropriateness,treatment received, over usage ofequipment/ materials, and consistency with billing rules.
• Apply scheme rules, clinicalpolicies, and protocols
• Liaise with the medical advisor if necessary
• Review and maintain clinical auditing rules (CARM) annually.
• To identify hospital trends andclaiming patterns with the objective of changing provider behavior and giving continuous feedback to the business.
• Clinical support to provider network team and discussing identified trends to provider team.
• Attend quarterly HRM operationalmeetings and feedback regardingtrends and application of billingguidelines.
• Action clinical auditing work andvolumes timeously and within set service level agreement
• Assist with auth-claim matching queries
• Ensure accurate savings isrecorded according to pay codes and reason codes; reviewing automated monthly savings report.

Competencies

• Excellent problem solving skills
• Accurate and vigilant
• Target oriented
• Ability to work under pressureand 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 todeliver a better service to customers and improv eperformance, including sharing knowledge and experience with others.
• Excellent verbal Communication