Clinical Auditor

Position Purpose: To audit, authorise and process the accurate payment of hospital and case management claims. Ensuring that patient treatment, material and equipment usage for each claim is in accordance with claim rules and regulations. Experience: 3 – 4 years Manage Care experience, of which a minimum of 2 years should have been in a hospital pre-authorisation call centre. Qualifications: Registered nurse diploma or degree (MANDATORY REQUIREMENT ) KEY PERFORMANCE AREAS Client service delivery and quality Follow procedures and cooperate with peers and leader for best possible service delivery Compliance and Risk Management Defined legal, statutory and regulatory compliance is maintained at the required standards Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary Contribute to cost savings within the department to assist with financial goals and targets Continuous improvement Operation Model Accurately audit claims according to contractual agreements/scheme rules Meet delivery objectives through working with other team members within and linked to the department / project Resolve operational performance variations and problems and escalated unresolved issues to higher levels Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery Operational Implementation of Strategy Keep up to date with operational changes implemented in response to important external influences Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement Operational Leadership Stakeholder Management Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in Regularly capture updates on cases and provide feedback to internal and external stakeholders KEY COMPETENCIES Knowledge Application of financial and risk assessment methodology Knowledge of scheme rules and contractual negotiations Knowledge and application of relevant legislation Knowledge and application of processes and procedure Skills Emails / HIP / Excel / Word Negotiation and Telephone Skills Communication Skills Business Writing Skills Relevant systems knowledge and application Ability to negotiate and influence Problem Solving Numerical Ability Customer Focus Attention to Accuracy and Detail Note: Company reserves the right to close the advert before specified closing date. PHA has its head office in Westville, KwaZulu-Natal. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits. #J-18808-Ljbffr