Professional Nurse: Clinical Auditor

4 weeks ago


Portelizabeth, South Africa Adzuna ZA B C2 Full time
Requirements:
  • A National Senior Certificate is essential.
  • It is essential to have a Nursing Diploma or Degree.
  • The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse.
  • MS Office / Office 365 proficiency.
  • Minimum of 2 yearsâ private hospital nursing experience.
  • Previous exposure to clinical auditing.
  • Examining information (interrogate claims data).
  • Articulating information.
  • Upholding standards.
  • Attention to detail.
  • Time management.
Â
Responsibilities and expectations but not limited to:
Internal Process:
  • Apply scheme rules, clinical policies and protocols to funding.
  • Action allocated hospital claims for audit within department KPIs and CMS requirements for claims payment.
  • Ensure accurate notes are made for all journals actioned on claims audited.
  • Assess prosthesis for PMB funding when benefits are exceeded or if there is no benefit.
  • Ensure accurate completion of authorisations on claim finalisation.
  • Refer LOC/ LOS / item or drug approval queries to case managers for resolution.
  • Act as clinical support to non-clinical hospital claim auditors in terms of hospital tariff applications and clinical guidance (e.g. procedures, devices and drug utilisation).
  • Survey claims for correct application of tariff and refer discrepancies to the relevant team.
  • Review retrospective claim approvals and send journal instructions for additional payments to the relevant team.
  • Review hospital claims for clinical appropriateness, treatment authorised, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.
Customer Service:
  • Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timeous feedback.
  • Escalate queries to the relevant team or stakeholder.
  • Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
  • Resolve claim queries accurately and timeously.
  • Build and maintain relationships with internal and external stakeholders.
  • Reduce claim rejections to ensure members are not held liable for unnecessary costs.
People:
  • Build strong relationships through expressing positive expectations.
  • Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
  • Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
  • Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
Finance:
  • Identify opportunities to enhance cost effectiveness and increase operational efficiency.
  • Manage financial and other company resources under your control with due respect.
  • Provide input into the risk identification processes and communicate recommendations in the appropriate forum.
Â
Please note should you not receive a response within two weeks of applying you may assume that your application was unsuccessful.

  • Portelizabeth, South Africa Headhunters Full time

    Job Title: Professional Nurse: Clinical AuditorWe are seeking a highly skilled and experienced Professional Nurse: Clinical Auditor to join our team at Headhunters. As a key member of our team, you will be responsible for ensuring the accuracy and integrity of clinical audits, providing expert clinical guidance, and building strong relationships with...


  • Portelizabeth, South Africa Headhunters Full time

    Requirements: A National Senior Certificate is essential. It is essential to have a Nursing Diploma or Degree. The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse. MS Office / Office 365 proficiency. Minimum of 2 years’ private hospital nursing experience. Previous exposure to clinical auditing. ...


  • Portelizabeth, South Africa Immploy Full time

    Clinical Leadership Opportunity at Immploy **Job Summary:** Immploy is seeking a highly skilled and experienced Clinical Practice Manager to join our team. As a key member of our clinical leadership team, you will be responsible for managing and coordinating clinical practice and resources within the unit to achieve company and hospital objectives of...


  • Portelizabeth, South Africa Immploy Full time

    Job Opportunity at Immploy **Job Title:** Unit Manager Specialist Qualified **Job Summary:** Immploy is seeking a highly skilled and experienced Unit Manager Specialist Qualified to join our team. As a key member of our healthcare operations team, you will be responsible for managing and coordinating clinical practice and resources within the unit to...

  • Nursing Director

    1 week ago


    Portelizabeth, South Africa Immploy Full time

    Job Description **Key Responsibilities:** As a Nursing Manager- General Ward at Immploy, you will be responsible for leading and coordinating the nursing function within the hospital. Your primary objective will be to manage and implement hospital and company strategic objectives related to growth, quality, and people. **Requirements:** * A degree or...

  • Nursing Director

    2 weeks ago


    Portelizabeth, South Africa Immploy Full time

    Job OverviewImmploy is seeking a highly skilled Nursing Manager to lead our General Ward team.Responsibilities:* Manage and coordinate the nursing function within the hospital, aligning with strategic objectives* Lead and develop a high-performing team to deliver exceptional patient care* Collaborate with hospital and company stakeholders to drive growth,...

  • Nursing Director

    2 weeks ago


    Portelizabeth, South Africa Edge Executives Full time

    Job Title: Nurse ManagerEdge Executives is seeking a highly skilled and experienced Nurse Manager to lead our nursing team in delivering exceptional patient care.Key Responsibilities:Leadership and Team Management: Provide strategic direction and guidance to nursing staff, fostering a culture of continuous improvement and high-performance.Patient Care...

  • Nursing Director

    7 days ago


    Portelizabeth, South Africa Edge Executives Full time

    Job Title: Nurse ManagerEdge Executives is seeking a highly skilled and experienced Nurse Manager to join our team. As a key member of our healthcare leadership team, you will be responsible for overseeing the nursing function in our General Wards, ensuring the delivery of optimal patient care in line with hospital standards and procedures.Key...

  • Nurse Manager

    3 weeks ago


    Portelizabeth, South Africa Adzuna ZA B C2 Full time

    Key Responsibilities:Manage the nursing function in the General Wards to ensure the delivery of optimal patient care in line with hospital standards and proceduresLead, mentor, and coordinate the nursing staff to foster a culture of continuous improvement and high-performanceEnsure compliance with nursing policies, procedures, and protocols, maintaining the...

  • Nurse Manager

    3 weeks ago


    Portelizabeth, South Africa Edge Executives Full time

    Key Responsibilities: Manage the nursing function in the General Wards to ensure the delivery of optimal patient care in line with hospital standards and procedures Lead, mentor, and coordinate the nursing staff to foster a culture of continuous improvement and high-performance Ensure compliance with nursing policies, procedures, and protocols, maintaining...


  • Portelizabeth, South Africa Immploy Full time

    Job Description The successful candidate will be responsible for managing, leading and coordinating the nursing function within the hospital in line with hospital and company strategic objectives of growth, quality and peopleRequirements: Degree / Diploma in Nursing Post-graduate qualification in Nursing Management Current registration with South African...


  • Portelizabeth, South Africa Edge Executives Full time

    Job Title: Theatre ManagerEdge Executives is seeking a highly skilled and experienced Theatre Manager to lead our theatre operations team. As a key member of our healthcare services team, you will be responsible for ensuring clinical excellence and patient safety in our theatre complex.Key Responsibilities:Theatre Operations Management: Oversee the...


  • Portelizabeth, South Africa Immploy Full time

    Immploy is seeking a skilled Theatre Manager to lead our clinical practice and resources within the units. The successful candidate will be responsible for achieving the Company & Hospital strategic objectives of quality, growth, and people. Key responsibilities include managing and coordinating clinical practice and resources, as well as ensuring compliance...

  • Theatre Manager

    2 weeks ago


    Portelizabeth, South Africa Adzuna ZA B C2 Full time

    Key Responsibilities:Manage and coordinate theatre operations to ensure clinical excellence and patient safetyOversee the clinical practice within the theatre complex, ensuring adherence to hospital and healthcare regulationsLead, mentor, and manage a team of healthcare professionals to foster a collaborative working environmentEnsure compliance with...

  • Theatre Manager

    2 weeks ago


    Portelizabeth, South Africa Edge Executives Full time

    Key Responsibilities: Manage and coordinate theatre operations to ensure clinical excellence and patient safety Oversee the clinical practice within the theatre complex, ensuring adherence to hospital and healthcare regulations Lead, mentor, and manage a team of healthcare professionals to foster a collaborative working environment Ensure compliance with...

  • Unit Director

    1 week ago


    Portelizabeth, South Africa Edge Executives Full time

    Job Title: Unit ManagerEdge Executives is seeking a highly skilled and experienced Unit Manager to lead our clinical operations and ensure the delivery of high-quality patient care.Key Responsibilities:Lead and Manage Clinical Operations: Oversee the day-to-day operations of the unit, ensuring that patient care needs are met and unit goals are...

  • Unit Manager

    3 weeks ago


    Portelizabeth, South Africa Edge Executives Full time

    Key Responsibilities: Lead and manage the units clinical operations to ensure the delivery of high-quality patient care Effectively allocate and manage resources to meet patient care needs and unit goals Ensure adherence to clinical protocols and maintain compliance with healthcare standards Build strong relationships with patients, families, and...

  • Unit Manager

    3 weeks ago


    Portelizabeth, South Africa Adzuna ZA B C2 Full time

    Key Responsibilities:Lead and manage the units clinical operations to ensure the delivery of high-quality patient careEffectively allocate and manage resources to meet patient care needs and unit goalsEnsure adherence to clinical protocols and maintain compliance with healthcare standardsBuild strong relationships with patients, families, and...


  • PortElizabeth, South Africa Premium Consulting Full time

    Job Title: Registered Nurse LocumJob Summary:We are seeking a skilled Registered Nurse to join our team at Premium Consulting in Port Elizabeth. The successful candidate will be responsible for providing high-quality patient care and working collaboratively with our team to deliver exceptional healthcare services.Key Responsibilities:Provide nursing care to...


  • PortElizabeth, South Africa Premium Consulting Full time

    Job Title: Registered Nurse LocumJob Summary: We are seeking a skilled and experienced Registered Nurse to join our team at Premium Consulting.Key Responsibilities:Provide high-quality patient care and support to individuals in need.Work collaboratively with healthcare professionals to deliver effective patient outcomes.Develop and implement individualized...