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
- Registered Nurse with Degree or Diploma (General, Psychiatric, Community 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
- Review specific hospital claimsfor clinical appropriateness, treatment received, over usage of equipment/ 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.
