Registered Professional Nurse: Clinical Auditor - Hospital

SUMMARY:
QUALIFICATIONS AND EXPERIENCE:

• Matric essential.
• Nursing Diploma or Degree essential.
• Minimum of 2 years’ private hospital nursing experience.
• Minimum of 1 years’ administrative exposure to the medical scheme industry.
• Minimum of 1 years’ exposure to hospital claim processes, billings and tariffs.
• Must be registered with SANC (South African Nursing Council) as a Registered Nurse.
• Excellent understanding of the Medical Schemes Act, as well as PMB legislation.
• Sound knowledge of ICD-10 and procedural coding.
• MS Office proficiency essential.
• Previous exposure to clinical auditing is highly advantageous
• Open to SA citizens with a clear criminal and credit history.
• Valid unendorsed Driver’s License with own vehicle (advantageous).

• Review hospital claims for clinical appropriateness, treatment authorised, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.
• 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 claim team.
• Review retrospective claim approvals and send journal instructions for additional payments to the claims team.

• 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.

• 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.

• 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.

• Attention to detail, goal orientated and a desire to achieve your objectives.
• Teamwork.
• Examining information (interrogate claims data).
• Articulating information.
• Upholding standards.
• Accountability.
• Attention to detail.
• Time management.
• Highly organised, good at multi-tasking and able to deal with people at all levels.

POSITION INFO:
Registered Professional Nurse: Clinical Auditor - Hospital

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