Clinical Auditor

2 weeks ago

Johannesburg, Gauteng, South Africa Fusion Personnel Full time

Minimum Education: Nursing Qualification (Nursing Diploma as a registered nurse)

Minimum Experience: 3 to 5 years (previous clinical auditing experience in a managed healthcare environment is essential)

Duties and Requirements includes but is not limited to the following:

  • Knowledgeable of the Medical Schemes Act and Government Gazette on tariffs
  • Vet hospital accounts under the guidance of the gazette
  • Use clinical guidelines and protocols when vetting accounts
  • Liaise with other members of the team and other departments
  • Daily auditing of captured accounts
  • Align hospital accounts with authorization on the system
  • Checking accounts for non-chargeable items - as per gazette
  • Evaluation of accounts for technical correctness using sound medical judgment
  • Reconcile hospital accounts
  • Deal with external auditors queries regarding payment of hospital accounts
  • Involved with mapping of new tariffs, by identifying them & sending requests to IT
  • Provide weekly reports to management
  • Investigate claims against daily reports
  • Capture authorizations on the IMED system
  • Handle member/hospital queries regarding hospital accounts payment
  • Schedule the weekly roster for the clinical auditors
  • Work with other healthcare personnel within the organization
  • Provide clinical expertise within the organization where required
  • Negotiation of discounts and credits with hospitals
  • Reversal of claims and provide feedback to service providers
  • Training of staff within the organization

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