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Specialist Clinical Auditor

3 months ago

Pretoria, Gauteng, South Africa H2R Africa Full time
valid registration with SANC. Also financial background working in the accounts department of a hospital is a crucial requirement.


Minimum 2 years experience working within a private hospitals account department responsible for raising accounts with and billing medical schemes.

Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e., ICD10s, CPT4, NRPL, PMB conditions and clinical protocols.

Thorough, well-grounded clinical knowledge of the pre-authorisation, case management and billing of hospital admissions (including Length of Stay and Level of Care).

Outcome focused with the ability to manage competing demands.
Excellent verbal and written communication skills.
Ability to liaise with external (clinicians and healthcare facilities) and internal (colleagues across all service areas) parties.
Demonstrated ability to effectively deal with emotionally charged and stressful situations.
Self-motivator and the ability to work effectively in an independent environment.
Good organisational and task prioritisation skills.
Outstanding multitasking skills.
High degree of accuracy and attention to detail.
Compile and submit relevant reports in accordance with strict deadlines.
Results orientated.
Maintaining confidentiality of information

A clinical auditor has a wide range of responsibilities, which include, but are not limited to:
Auditing of hospital accounts within the agreed SLA for the contracted client medical schemes.
Communication to service providers on the items disputed.
Interact with the Medical Advisors and Clinical Manager for clinical advice.
Identifying and communicate trends on fraud, waste and abuse.

option and co-payments where applicable.
Audit the accounts ensuring that all charges are valid and clinically appropriate.
Performing audits of medical records to identify incomplete documentation or errors and neglect in patient care.
Conducting research on new healthcare technologies, treatments or procedures to determine their safety and efficiency
Preparing reports detailing and summaring findings from clinical audits, including recommendations for improvements
Ensuring that hospital and clinic policies and procedures are being followed by staff.