Clinical Auditor MMH251008-8

Clinical Auditor MMH -8

Role Purpose

Conduct timely and accurate audits of hospital claims, focusing on customer centricity and maintaining the quality of service rendered to scheme members within the benefit design.

Requirements

• Bachelor's degree or equivalent qualification in a field such as Theatre Technique, Intensive Care Unit (ICU), Science in Nursing (BSN), Health Information Management (BHIM), Health Administration, Healthcare Management, or a related field is essential.
• Registered nurse or midwife with the South African Nursing Council (SANC).
• 3 – 5 years clinical experience in a healthcare environment (i.e., insurance / healthcare organisation / healthcare consulting firm).
• Familiarity with medical coding systems (such as ICD-10) and accurate application for coding diagnoses, procedures, and services.
• Understanding of relevant healthcare regulations, laws, compliance requirements, and medical coding guidelines.
• Proficiency in reviewing and interpreting medical documentation, including records, notes, reports, and summaries.
• Knowledge of medical terminology, diagnoses, procedures, treatment protocols, and healthcare benefit plans.
• Understanding of billing practices, fee schedules, reimbursement methodologies, and hospital billing guidelines.
• Knowledge of clinical auditing methodologies, including data analysis, sampling methods, and audit tools.
• Knowledge of quality assurance principles and methodologies in healthcare.
• Familiarity with healthcare information systems, electronic health records (EHRs), claims management systems, and relevant auditing software.
• Understanding of Prescribed Minimum Benefits (PMB) legislation and its implications for healthcare coverage.
• Oracle system knowledge or familiarity with other claims management software. Knowledge of Clinical Auditing and Risk Management (CARM) rules.

Responsibilities

PROCESS

CLIENT

PEOPLE

FINANCE

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