Clinical Auditor X5 (Cape Town, Johannesburg, Durban or Gqeberha) at Momentum Metropolitan Holdings Limited

Role Purpose    

• To ensure claims are audited timeously and accurately, with a focus on reducing wastage and abuse, and to ensure that all claims are processed in accordance with authorisations and established criteria.

Requirements    
Education

• Matric/Grade 12 - Essential
• Bachelor's degree or equivalent qualification in a field such as Nursing - Essential
• Intensive Care Unit (ICU), Science in Nursing (BSN), Health Information Management (BHIM), Health Administration, Healthcare Management, or a related field - Advantageous

Experience 

• 3 - 5 years of clinical experience in a healthcare environment - Essential
• Previous exposure to clinical auditing - Advantageous 
• Proficiency in MS Office / Office 365 - Essential

Professional Licensing Requirements

• Registered nurse with the South African Nursing Council (SANC) - Advantageous 

Knowledge

• Familiarity with medical coding systems (such as ICD-10) and accurate application for coding diagnoses, procedures, and services.
• Understanding of relevant healthcare regulations, laws, compliance requirements, and medical coding guidelines.
• Proficiency in reviewing and interpreting medical documentation, including records, notes, reports, and summaries.
• Knowledge of medical terminology, diagnoses, procedures, treatment protocols, and healthcare benefit plans.
• Understanding of billing practices, fee schedules, reimbursement methodologies, and billing guidelines.
• Knowledge of clinical auditing methodologies, including data analysis, sampling methods, and audit tools.
• Knowledge of quality assurance principles and methodologies in healthcare.
• Familiarity with healthcare information systems, claims management systems, and relevant auditing software.
• Understanding of Prescribed Minimum Benefits (PMB) legislation and its implications for healthcare coverage.
• Knowledge of Clinical Auditing, Risk Management and Clinical and Billing rules. 

Duties & Responsibilities    
Process 

• Apply scheme rules, clinical policies and protocols to support funding of claims.
• Action allocated 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 PMB funding in collaboration with MCO (Managed Care Organisation) as well as approved PMB manual.
• Act as clinical support to non-clinical Claim Auditors in terms of billing rules and any other funding rules.
• Survey claims for correct application of tariff and refer discrepancies to the relevant team.
• Review retrospective claim approvals and refer for additional clinical information to Medical Advisors.
• Review claims for clinical appropriateness.
• Analyse hospital claims data and trends to identify patterns and behaviour, proactively provide feedback to the business to influence provider behaviour, and implement changes to improve claims management processes.

Client

• Build and maintain relationships with clients and internal and external stakeholders.
• Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed.
• Make recommendations to improve client service and fair treatment of clients within area of responsibility.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
• Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

People

• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
• Positively influence and manage change and offer specialist support where required.
• 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.
• Take ownership for driving career development.

Finance

• Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
• Identify solutions to enhance cost effectiveness and increase operational efficiency.
• Implement and provide input into governance processes, systems and legislation within area of specialisation.
• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes.
• Provide input into the risk identification processes development and communicate recommendations in the appropriate forum.

Competencies    

• Problem-solving skills.
• Critical thinking skills.
• Collaboration skills.
• Analytical skills.
• Data analysis skills.
• Adopting Practical Approaches.
• Following Procedures.
• Examining Information.

Deadline:25th August,2025