Reference Number MMH240718-4
Job Title Clinical Auditor
Position Type Permanent
Role Family Medical
Cluster Health Solutions
Remote Opportunity None of the time
Location - Country South Africa
Location - Province KwaZulu-Natal
Location - Town / City Durban, South Africa
Introduction
Momentum Health Solutions, anentity of Momentum MetropolitanHoldings delivers sustainable, integrated health solutions thatmeet the needs of clients in thedifferent segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.
Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page.
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
- 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
- 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.
- 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
