Clinical Auditor (Registered Nurse)
Reference: PE000173-HP -2
The hiring organisation offers a minimum six-month fixed term contract opportunity to an experienced Registered Nurse with private hospital nursing experience.
Ideally you will be based in Port Elizabeth, EC but the possibility exists of a candidate being based in Durban, Bellville or Centurion.
ROLES AND RESPONSIBILITIES:
Reporting to the Team Leader, your performance areas include, but are not limited to:
INTERNAL PROCESS
- Apply scheme rules, clinical policies and protocols to funding.
- Action allocated hospital claims for audit within department KPIs and CMS requirements for claims payment.
- 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 (e.g. procedures, devices and drug utilisation).
- Survey claims for correct application of tariff and refer discrepancies to the relevant team.
- Review retrospective claim approvals and send journal instructions for additional payments to the relevant team.
- Review hospital claims for clinical appropriateness, treatment authorised, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.
CUSTOMER SERVICE - Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timeous feedback.
- Escalate queries to the relevant team or stakeholder.
- Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
- Resolve claim queries accurately and timeously.
- Build and maintain relationships with internal and external stakeholders.
- Reduce claim rejections to ensure members are not held liable for unnecessary costs.
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.
- Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
FINANCE - Identify opportunities to enhance cost effectiveness and increase operational efficiency.
- Manage financial and other company resources under your control with due respect.
- Provide input into the risk identification processes and communicate recommendations in the appropriate forum.
QUALIFICATIONS AND EXPERIENCE: - 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.
IMPORTANT ATTRIBUTES - Teamwork.
- Examining information (interrogate claims data).
- Articulating information.
- Upholding standards.
- Accountability.
- Attention to detail.
- Time management.
Location: Port Elizabeth, or Bellville, Durban or Centurion
Profile: Healthcare Services
Career Level: 2+ years.
Employment: Contract - six Month FTC
E.E. / Non-EE: Strictly EE (ACI, male or female)
Working Hours: Monday to Friday. 08H00 - 17H00
Remuneration: Market related CTC basic.
Short listed candidates may be expected to complete and pass assessments before moving to the next stage of the recruitment process. Should you not be contacted within two weeks, please consider your application unsuccessful. #J-18808-Ljbffr
