Clinical Auditor
| Location | Bellville, South Africa |
| Date Posted | October 27, 2020 |
| Category |
Audit
|
| Job Type |
Full-time
|
| Currency | ZAR |
Description
Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.
Duties & Responsibilities
Role Purpose
Ensuring hospital claims are audited timeously and accurately as per our service level agreement, focusing on customer centricity and the quality of service rendered to the member within the scheme's benefit design.
What you're going to do
- Review specific hospital claims for clinically appropriateness, treatment received, over usage of equipment / materials and consistency with billing rules;
- Apply scheme rules, clinical policies and protocols;
- Liaise with the medical advisor if necessary;
- Review and maintain clinical auditing rules (CARM) annually;
- Review hospital network billing guidelines annually and feedback to the business;
- To identify hospital trends and claiming patterns with the objective of changing provider behaviour and giving continuous feedback to the business;
- Clinical support to provider network team and discussing identified trends to provider team;
- Attend quarterly HRM operational meetings and feedback regarding trends and application of billing guidelines;
- Action clinical auditing work and volumes timeously and within set service level agreement;
- Assist with auth-claim matching queries
- Ensure accurate savings is recorded according to pay codes and reason codes; reviewing automated monthly savings report;
Desired Experience & Qualification
- Registered Nurse and/or midwife essential
- Diploma in Theatre Technique or ICU (or relevant experience)
- RPL course would be an advantage
- At least 5 years post graduate clinical experience
- At least 3 years industry experience
- Strong knowledge of PMB legislation is an advantage
- Understanding of hospital billing guidelines is an advantage
- Strong Oracle system knowledge and CARM rules is an advantage
Disclaimer
Shortlisted candidates will be subject to the following statutory checks:
•References
•Credit
•Criminal
•Qualification
•Psychometric assessments
- Note that we reserve a right not to fill this vacancy.
- Should you not be contacted within two weeks, please consider your application unsuccessful.