Professional Nurse: Clinical Auditor - Gqeberha at Momentum Metropolitan Holdings Limited

Requirements

• 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

Duties & Responsibilities

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 authorisations on claim finalisation.
• 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 & drug utilisation).
• 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 authorised, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.

CUSTOMER SERVICE

• 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.

PEOPLE

• 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 specialisation.
• 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.

FINANCE

• 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.