Clinical Auditor

Position: Specialist Clinical Auditor
Reporting to: Senior Specialist Clinical Management
Location: On-site at the Head Office, Pretoria

**Purpose of the position**:
Clinical Auditors are responsible to ensure that medical facilities like hospitals, and other healthcare service providers comply with relevant healthcare billing, prizing, and coding rules and also follow clinical protocols. They routinely perform clinical account audits to ensure compliance to the set standards. Clinical auditors are tasked with identifying areas of improvement or gaps and recommend changes to clinical practices to ensure that optimum care is delivered to patients. This could include suggested changes to processes or procedures and/ or recommending the adoption and use of new healthcare technologies or equipment.

**Qualifications**:

- Registered Nurse
- Valid registration with SANC

**Skills and Competencies Required**:

- Minimum 2-3 years’ experience within a similar role within a managed healthcare or medical scheme environment
- Minimum 2 years’ experience working within a private hospital’s account department responsible for raising accounts with billing medical schemes
- Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e., ICD10’s, CPT4, NRPL, PMB conditions and clinical protocols
- Thorough, well-grounded clinical knowledge of the pre-authorisation, case management and billing of hospital admissions (including Length of Stay and Level of Care).
- Outcome focused with the ability to manage competing demands.
- Excellent verbal and written communication skills
- Ability to liaise with external (clinicians and healthcare facilities) and internal (colleagues across all service areas) parties.
- Demonstrated ability to effectively deal with emotionally charged and stressful situations
- Self-motivator and the ability to work effectively in an independent environment
- Good organisational and task prioritisation skills.
- Outstanding multitasking skills.
- High degree of accuracy and attention to detail.
- Compile and submit relevant reports in accordance with strict deadlines.
- Results orientated.
- Maintaining confidentiality of information.

**Summary of Responsibilities**:
A clinical auditor has a wide range of responsibilities, which include, but are not limited to:

- Auditing of hospital accounts within the agreed SLA for the contracted client medical schemes.
- Communication to service providers on the items disputed.
- Interact with the Medical Advisors and Clinical Manager for clinical advice.
- Identifying and communicate trends on fraud, waste, and abuse.

Ability to commute/relocate:

- Pretoria, Gauteng: Reliably commute or planning to relocate before starting work (required)

Application Deadline: 2023/04/28