Consultant: Clinical Auditor

2 weeks ago


Centurion, Gauteng, South Africa PPS Recruitment Full time

Job Advert Summary:

Applications are invited for the above-mentioned position, to be filled as soon as possible.

Minimum Requirements:

  • Nursing qualification.
  • Clinical Auditing experience
  • Minimum of 2 years' experience in the managed care environment

Duties and Responsibilities:

  • Conduct clinical audits on claims and costs to ensure correct payment of claims to providers and members
  • Accumulate/Investigate data using clinical experience to highlight risks and trends which might influence the costs to the scheme
  • Compile audit reports to point out trends and risks
  • Liaise with providers to develop and maintain relationships
  • Assist in the settlement of claims disputes to ensure correct payment of claims
  • Research new medical and surgical instrumentation and products to keep the company abreast of changes in the industry
  • Provide Clinical input into work directives and protocols to assist PMSA with clinical decisions
  • Participate in negotiations with service providers in order to assist the Scheme with the cost effective management of resources
  • Required to assist with the review of policies, protocols and formularies from a clinical and financial position
  • Evaluate current medicine usage trends and compare with those of local and international sources for best practice
  • Monitor medical literature and use evidencebased principles to generate enhancements in funding protocols
  • Review and research new drug trial results, in collaboration with the Medical Advisor
  • Answer clinical queries from Providers within the Schemes' SLA requirements
  • Perform tasks timeously and with necessary detail in response to issues raised
  • Provide input and support to the Clinical Committees, MHC meeting and other committees as and when required
  • Assisting with all adhoc requests on any clinical matters when required
  • Maintain information gathered on knowledge management portals
  • Proactively identify and manage potential problems/escalations within customer base with appropriate resolution plans


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