Consultant: Clinical Auditor

3 weeks ago

Centurion, South Africa PPS Recruitment Full time

**Job Advert Summary**:
Applications are invited for the above-mentioned position, to be filled as soon as possible.

**Minimum Requirements**:

- Nursing qualification.
- Clinical Auditing experience
- Minimum of 2 years' experience in the managed care environment

**Duties and Responsibilities**:

- Conduct clinical audits on claims and costs to ensure correct payment of claims to providers and members
- Accumulate/Investigate data using clinical experience to highlight risks and trends which might influence the costs to the scheme
- Compile audit reports to point out trends and risks
- Liaise with providers to develop and maintain relationships
- Assist in the settlement of claims disputes to ensure correct payment of claims
- Research new medical and surgical instrumentation and products to keep the company abreast of changes in the industry
- Provide Clinical input into work directives and protocols to assist PMSA with clinical decisions
- Participate in negotiations with service providers in order to assist the Scheme with the cost effective management of resources
- Required to assist with the review of policies, protocols and formularies from a clinical and financial position
- Evaluate current medicine usage trends and compare with those of local and international sources for best practice
- Monitor medical literature and use evidence-based principles to generate enhancements in funding protocols
- Review and research new drug trial results, in collaboration with the Medical Advisor
- Answer clinical queries from Providers within the Schemes' SLA requirements
- Perform tasks timeously and with necessary detail in response to issues raised
- Provide input and support to the Clinical Committees, MHC meeting and other committees as and when required
- Assisting with all adhoc requests on any clinical matters when required
- Maintain information gathered on knowledge management portals
- Proactively identify and manage potential problems/escalations within customer base with appropriate resolution plans

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