Professional Nurse: Clinical Auditor MMH251113-2
1 week ago
Professional Nurse: Clinical Auditor MMH -2 Join to apply for the Professional Nurse: Clinical Auditor MMH -2 role at Momentum . Role Purpose To ensure hospital claims are audited timeously and accurately with the focus on reducing wastage and abuse, as well as to ensure that claims are processed according to authorisations. 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. 1–2 Years’ private hospital nursing experience is essential. Previous exposure to clinical auditing is highly advantageous. MS 365 proficiency. Duties and Responsibilities Internal Process Apply scheme rules, clinical policies and protocols to funding. Action allocated hospital claims for audit within department key performance indicators and CMS requirements for claims payment. Ensure accurate notes are made for all journals actioned on claims audited. Assess prosthesis for prescribed minimum benefit funding when benefits are exceeded or if there is no benefit. Ensure accurate completion of authorisations on claim finalisation. Refer relevant 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. 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 timely 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 timeliness. 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. Seniority level Entry level Employment type Full-time Job function Health Care Provider #J-18808-Ljbffr
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Gqeberha, South Africa Momentum Full timeProfessional Nurse: Clinical Auditor MMH -2 Join to apply for the Professional Nurse: Clinical Auditor MMH -2 role at Momentum . Role Purpose To ensure hospital claims are audited timeously and accurately with the focus on reducing wastage and abuse, as well as to ensure that claims are processed according to authorisations. Requirements A National Senior...
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Professional Nurse: Clinical Auditor
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Gqeberha, South Africa Hire Power Full timeProfessional Nurse: Clinical Auditor, with private hospital nursing background.
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Clinical Auditor Nurse: Hospital Claims
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Gqeberha, South Africa Momentum Full timeA healthcare provider in Gqeberha is seeking a Professional Nurse: Clinical Auditor to ensure timely and accurate hospital claims auditing. The role requires a National Senior Certificate, a Nursing Diploma or Degree, SANC registration, and 1-2 years of nursing experience. This full-time position demands proficiency in MS 365 and offers a chance to build...
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