Clinical Auditor

2 weeks ago

Pretoria, Gauteng, South Africa Discovery Full time
Discovery Health
Clinical Auditor Job level - Staff level
About Discovery
Discovery's core purpose is to make people healthier and to enhance and protect their lives.

We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery.

Our fast-paced and dynamic environment enables smart, self-driven people to be their best.

As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.

Key Purpose
To identify and manage potential fraud and abuse for all schemes under administration within the health business.

Areas of responsibility may include but are not limited to: To identify and prevent scheme exposure to fraud, waste and abuse related to inappropriate or erroneous claims submitted by healthcare providers.

To analyse and audit claims for clinical appropriateness, adherence to billing guidelines and identify potential areas of abuse.

Analyse provider, member, and facility spike/outlier reports/data to identify any fraudulent trends and once identified, provide full insight into all aspects of the case including the how, why and when the potential fraud/abuse was committed.

Support and work closely with the forensic investigations team regarding clinical coding and clinical audits on healthcare professionals.

Work with manager/team leader to develop and recommend risk mitigation strategies and/or reports for tracking activities to proactively curb waste and abuse.

Manage the workload to ensure that cases/reports are handled appropriately and resolved in a timely manner. Provide prompt & accurate feedback to all parties involved in an investigation or area of concern. Personal Attributes and Skills Expresses opinions, information, and key points of an argument clearly. Monitors performance against deadlines and milestones. Sets high standards for quality and quantity. Makes rational judgments from the available information and analysis. Takes initiative and works under own direction - self-starter. Focuses on customer needs. Upholds ethics and values; demonstrates integrity. Be flexible in handling multiple projects and audits simultaneously. Education and Experience

Minimum requirements:
Clinical Diploma NHRPL coding knowledge across all/any practice types. ICD-10 coding knowledge. Knowledge of Discovery Health products

Computer Knowledge:

Microsoft literacy essential:
Excel, Word and Power point Outlook knowledge essential Discovery systems (e.g. Claims; DCS etc.)

EMPLOYMENT EQUITY
The Company's approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.
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