Clinical Auditor

4 weeks ago

Durban, South Africa Talent Pal Full time

**Introduction**

Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.

**Role Purpose**

Ensuring hospital claims are audited timeously and accurately as per our service level agreement, focusing on customer centricity and the quality of service rendered to the member within the scheme's benefit design.

**Requirements**:

- Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife) is essential.
- Diploma in Theatre Technique or ICU (or minimum 3 years relevant experience) is essential.
- RPL course would be an advantage.
- At least 5 years of post-graduate clinical experience is essential.
- At least 3 years of Managed Care/Medical Aid industry experience is essential.
- Strong knowledge of PMB legislation, Clinical Coding (ICD 10, CPT & NHRPL), hospital and doctor's billing guidelines is highly advantageous.
- Strong Oracle system knowledge and CARM rules is an advantage.

**Duties & Responsibilities**
- Review specific hospital claims for clinical appropriateness, treatment received, over usage of equipment/ materials, and consistency with billing rules.
- Liaise with the medical advisor if necessary.
- Review and maintain clinical auditing rules (CARM) annually.
- Review hospital network billing guidelines annually and feedback to the business.
- To identify hospital trends and claiming patterns with the objective of changing provider behavior and giving continuous feedback to the business.
- Clinical support to provider network team and discussing identified trends to provider team.
- Action clinical auditing work and volumes timeously and within set service level agreement.
- Assist with auth-claim matching queries.
- Ensure accurate savings is recorded according to pay codes and reason codes; reviewing automated monthly savings report.

**Competencies**
- Excellent problem solving skills
- Accurate and vigilant
- Target oriented
- Ability to work under pressure and meet deadlines
- Analytical thinking and investigative mind
- Conceptual thinking
- Attention to Details
- Self-Motivation
- Teamwork focused
- Analytical Thinking
- Good time management skills
- Quality orientated
- Trend management focus
- The ability to apply, maintain and expand professional and technical knowledge in order to deliver a better service to customers and improve performance, including sharing knowledge and experience with others.
- Excellent verbal Communication

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