Professional Nurse: Clinical Auditor

SUMMARY:

Location: Gqeberha, Eastern Cape, South Africa

Minimum Requirements

• National Senior Certificate (Matric) — Essential
• Nursing Diploma or Degree — Essential
• Registered with the South African Nursing Council (SANC) — Essential
• 1–2 years private hospital nursing experience — Essential
• Exposure to clinical auditing — Highly advantageous
• MS 365 proficiency
• Clear criminal history

Key Responsibilities

• Audit allocated hospital claims according to KPIs and CMS requirements.
• Apply scheme rules, clinical protocols, and funding policies.
• Review claims for clinical appropriateness, treatment alignment, tariff application, and high-cost medication usage.
• Validate prosthesis usage and PMB funding.
• Record accurate notes on all audited journals.
• Finalise authorisations and refer complex queries to case managers.
• Provide clinical guidance to non-clinical claim auditors.
• Investigate, resolve, and escalate claim queries as required.
• Maintain professional stakeholder relationships.
• Identify opportunities to enhance cost effectiveness and operational efficiency.

Core Competencies

POSITION INFO:
Professional Nurse: Clinical Auditor, with private hospital nursing background.