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Auditor Clinical Excellence
3 weeks ago
About the Role:
This is a fantastic opportunity for a Registered Nurse with private hospital experience to join our team as a Clinical Auditor. The successful candidate will be responsible for reviewing hospital claims for clinical appropriateness, treatment authorised, over-usage of equipment/materials, application of billing rules, and high-cost medication appropriateness. This role also involves providing accurate information and advice to stakeholders, resolving claim queries accurately and timeously, and building and maintaining relationships with internal and external stakeholders.
Responsibilities:
- Internal Process: Ensure accurate notes are made for all journals actioned on claims audited, assess prosthesis for PMB funding when benefits are exceeded or if there is no benefit, ensure accurate completion of authorisations on claim finalisation, refer LOC/ LOS / item or drug approval 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.
- Customer Service: Provide accurate information and advice to stakeholders to ensure they receive the appropriate service, resolve claim queries accurately and timeously, build and maintain relationships with internal and external stakeholders.
- 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.
- Finance: Identify opportunities to enhance cost effectiveness and increase operational efficiency.
Key Requirements:
- Matric essential.
- Completed Nursing Diploma or Degree essential.
- The incumbent must be registered with the South African Nursing Council (SANC) as a Registered Nurse.
- MS Office / Office 365 proficiency.
- Fluent in English – essential requirement.
- Open to SA citizens with a clear criminal and credit history.
- Valid unendorsed Driver's License with own vehicle (preferred).
- Minimum of 2 years' private hospital nursing experience.
- Previous exposure to clinical auditing is highly advantageous.
