Clinical Auditing Specialist

4 weeks ago

Sandton, South Africa Discovery Ltd. Full time

**Business Unit**:Discovery Health**Function**:Forensics/Fraud/Fiduciary Services**Date**:7 Jun 2024- Discovery Health- Clinical Auditing Specialist**About Discovery**
- Discovery’s core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fast-paced and dynamic environment enables smart, self-driven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.**About Strategic Risk Management**
- SRM is a business critical department in Discovery Health, holding the responsibility for ensuring sustainable and equitable management of scheme funds to deliver patient care. It houses multiple teams of experts in clinical, actuarial, and managerial roles all striving to gain the highest value for members who need care. SRM is a fast paced, highly visible and complex area of healthcare management with opportunities for executive visibility, external client engagement and innovation.**Key Purpose**
- To identify and manage potential fraud and abuse for all schemes under administration within the health business. Engagement with providers and senior industry bodies with regard to robust risk management, fraud and billing rule policy setting and impact. Has the authority, accountability, and responsibility to manage specific fraud initiatives to achieve specific objectives.**Areas of responsibility may include but not limited to**
- To identify and prevent scheme exposure to fraud, waste and abuse related to inappropriate or erroneous claims submitted by healthcare providers and members.
- To analyze and audit claims for clinical appropriateness, adherence to billing guidelines and potential areas of abuse.
- Coordinate and conduct activities with the main stakeholders in order to create the relevant documentation for external engagement.
- Planning and managing the execution of large and complex forensic audit engagements.
- Provide a professional, disciplined, industry referenced and forward thinking approach to evaluating and improving the effectiveness of fraud risk clinical auditing.
- Engagement with providers and senior industry bodies.
- Lead discussions with external stakeholders with regards to areas of concern identified in order to resolve the issues in a way that is beneficial to the schemes under administration.
- Analyze provider, member and scheme reports/data to identify any fraudulent trends and once identified, provide full insight into all aspects of the case including the how, why and when the potential fraud/abuse was committed.
- Support and work closely with the forensic investigations team regarding clinical coding and clinical audits on healthcare professionals.
- Support and work closely with the fraud intelligence team to create or enhance new risk tools to identify and prevent fraud, waste and abuse.
- Recommend risk mitigation strategies/controls and/or reports for tracking activities to proactively curb waste and abuse.
- Where necessary, engage with professional societies to obtain opinion on trends identified.
- Manage the workload to ensure that cases/reports are handled appropriately and resolved in a timely manner.
- Provide prompt & accurate feedback to all parties involved in an investigation or area of concern.
- Actively contribute to the efficient and effective functioning of Fraud Risk services.

**Personal Attributes and Skills**
- The successful Incumbent must be able to demonstrate the following competencies:
- Expresses opinions, information, and key points of an argument clearly
- Monitors own and teams’ performance against deadlines and milestones.
- Deciding and initiating action. Capable of recognising the need for action, considering possible risks, and taking responsibility for results.
- Analysing of data
- Entrepreneurial and Commercial Thinking
- Excellent communication and presentation skills
- Persuading and Influencing
- Sets high standards for quality and quantity.
- Managing self. Takes initiative and works under own direction - self-starter.
- Capacity to plan, organise and control own work environment by setting appropriate priorities and achieving set objectives within a given time frame.
- Upholds ethics and values; demonstrates integrity.
- Be flexible in handling multiple projects simultaneously.
- The capacity to improve systems and processes to facilitate continuous improvement.
- Capacity to establish constructive and effective relationships.

**Education and Experience**
- Clinical degree
- Certified fraud examiner qualification
- Clinical coding qualification
- NHRPL coding knowledge across all/any practice types, with a minimum of 5 years’ experience
- Knowledge of Discovery Health products
- Practical knowledge of clinical au

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