File Assessor

2 months ago

Cape Town City Centre, South Africa Jobted ZA C2 Full time

The Bill Auditor is responsible for auditing patient files to ensure completeness and accuracy of billing, while adhering to the National Hospital Network (NHN) rules and agreements with medical schemes. The role ensures that all billing processes are accurate, timely, and compliant with hospital and payer regulations.

Duties will include but not be limited to:

- Print pro-forma invoices for allocated patient files
- Audit patient files according to company requirements and NHN agreements with medical schemes, including:
- Verifying the completeness of patient data (personal information, medical scheme details, admission and discharge dates)
- Reviewing eligibility tests, materials used, medications prescribed and administered
- Verifying surgical movements, theater minutes, prosthetics used, and equipment
- Ensuring Length of Stay (LOS) and Level of Care (LOC) matches medical scheme approvals
- Confirming the accuracy of admission types between the Hospital Information System (HIS) and patient files
- Document required corrections/amendments and escalate them to the Patient Administration Manager for resolution
- Verify corrections and process final billing on HIS after corrections are completed
- Perform End of Case (EOC) processes on MediKredit, investigating rejections, and resubmitting files when necessary
- For private patient claim files, finalize billing on HIS and forward to the Collections Department for further action
- Collaborate with Reception/Admissions, Case Management, Nursing, and Pharmacy staff to ensure accurate and timely final invoices
- Assist in minimizing delays and backlogs in the billing departmentFor paper claim files i.e. private patients (including COID and RAF patients), final bill the account on the HIS s as "paper" claim and forward patient files to the Collections Department for further management
- Complete, sign and file the Audit tool in the patients file
- Collaborate and build relationships with the with Reception/Admissions, Case Management, Nursing and Pharmacy staff to ensure that final invoices are generated without delays

Requirements:

- Grade 12 or equivalent qualification
- Enrolled Nurse qualification
- Registered Nursing qualification
- 2 to 5 years of experience as a Bill Auditor/File Assessor, preferably in a private hospital setting
- Strong knowledge of National Hospital Network reimbursement models
- Proficiency in Hospital Information Systems (e.g., SAP or similar)

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