Talent Pool: Clinical Auditor MMH251111-2Momentum • Johannesburg, Gauteng, South Africa
Talent Pool : Clinical Auditor MMH251111-2
Momentum • Johannesburg, Gauteng, South Africa
2 days ago
Job descriptionFamiliarity 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. Review specific hospital claims for clinical appropriateness, treatment received, over usage of equipment / materials, and consistency with billing rules, with a focus on identifying potential fraudulent activities or billing errors. Apply scheme rules, clinical policies, and protocols to ensure compliance and accurate determination of claim eligibility and appropriateness. Conduct regular reviews and updates of clinical auditing rules (CARM) to ensure relevance, accuracy, and alignment with industry trends and regulatory changes. Review hospital network billing guidelines annually and provide feedback to the business for improvements, while actively seeking opportunities for cost savings and process efficiencies. Analyse hospital claims data and trends to identify patterns and behaviour, proactively provide feedback to the business to influence provider behaviour, and implement changes to improve claims management processes. Liaise with the medical advisor when needed to address complex cases or obtain specialised clinical expertise, ensuring accurate assessment and appropriate resolution. Provide clinical support to the provider network team, discussing identified trends, patterns, and potential areas for improvement to enhance service quality and compliance. Attend quarterly operational meetings, provide feedback on trends, and discuss the application of billing guidelines, while actively participating in internal and external training programs to enhance knowledge and skills related to clinical auditing techniques, fraud prevention, and industry advancements. Act as a subject matter expert and resource for colleagues, providing guidance, training, and support to enhance the overall knowledge and competency of the clinical auditing team. Commitment to ongoing learning and staying updated with industry trends, best practices, and regulatory changes in healthcare, clinical auditing, and relevant areas. Ensure accurate recording of savings according to pay codes and reason codes, contributing to financial tracking and reporting processes, with a focus on identifying opportunities for cost savings and process efficiencies. Collaborate with IT teams to optimise and leverage data analytics tools and systems to enhance audit processes, identify patterns, and develop proactive strategies for risk assessment, fraud detection, and cost containment.
Talent Pool : Clinical Auditor MMH -2
Momentum Johannesburg, Gauteng, South Africa
Role Purpose
The purpose of this role is to 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
Qualification & Experience
- Registered Nurse / Allied Health Professional is essential
- Registered Nurse with the South African Nursing Council (SANC) is essential
- Coding certification (ICD-10, CPT, DRG) - advantageous
- Minimum of 5 years working experience within managed care industry
Knowledge
Duties and Responsibilities
PROCESS
CLIENT
PEOPLE
FINANCE
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Human Resources
Referrals increase your chances of interviewing at Momentum by 2x.
#J-18808-Ljbffr
Create a job alert for this search
Clinical Auditor • Johannesburg, Gauteng, South Africa
Related jobs
Bring Order, Precision & Compliance to Patient Care.Are you a natural problem-solver who thrives in the details? Do you have a deep respect for structure, accuracy, and doing things the right way—e...Show more
)
Clinical Coach MMH251111-4
Momentum • Johannesburg, Gauteng, South Africa
Momentum Johannesburg, Gauteng, South Africa.Ensure comprehensive clinical risk management training, mentoring, and skills development, aligning business processes and system capabilities to optimi...Show more
Last updated: 1 day ago • Promoted
Clinical Project Manager IQVIA Biotech Oncology
IQVIA • Centurion, Gauteng, South Africa
Project Leads are an integral part of clinical trial delivery liaising with clinical teams to improve patients lives by bringing new drugs to the market faster.
The Project Lead is an essential memb...Show more
Last updated: 30+ days ago • Promoted
Senior Clinical Technologist
Mediclinic Group • Johannesburg, Gauteng, South Africa
Wits Donald Gordon Med Centre Parktown Johannesburg South Africa.Recruiter name : Nombulelo Florence Mpofu.Workplace Type : custWorkplaceType.
To deliver safe comprehensive and quality nursing care wi...Show more
Last updated: 30+ days ago • Promoted
Senior Technical Draughtsman
Level-Up • Germiston, South Africa
The Senior Technical Draughtsman will be responsible for creating detailed manufacturing drawings and documentation for steel and timber shopfitting fixtures.
Working closely with clients, project m...Show more
Last updated: 30+ days ago • Promoted
Auditor
Phakisa Holdings • Johannesburg, South Africa
Short Description / Purpose of Job : .To conduct comprehensive audits on all relevant Supply Chain Procurement contracts and systems (specifically Road Logistics) in alignment with all applicable Gov...Show more
Last updated: 1 day ago • Promoted
Clincal Trial Coord
Thermo Fisher Scientific • Johannesburg, Gauteng, South Africa
According to the specific role (Central or Local) coordinates oversees and.Performs department Internal Country and Investigator file reviews as.
Ensures allocated tasks are performed on time within...Show more
Last updated: 30+ days ago • Promoted
Business Development Manager (HealthcareDevelopment)
Boardroom Appointments • Kempton Park, South Africa
Head of Healthcare Development.Business Development Identify and target new business opportunities within the Healthcare sector.
Responsible for achieving sales target through lead generation, prosp...Show more
Last updated: 30+ days ago • Promoted
Clinical Associate
The Legends Agency • Johannesburg, South Africa
Our client is a fast-growing digital health enterprise dedicated to improving access to quality care for people living with chronic health conditions across sub-Saharan Africa.By combining technolo...Show more
Last updated: 30+ days ago • Promoted
Clinical Auditor (Remote)
NIVA Health • WorkFromHome, South Africa
Remote
Last updated: 2 days ago • Promoted
Intern Cardiac Clinical Technologist
Medtronic • Johannesburg, Gauteng, South Africa
At Medtronic you can begin a life-long career of exploration and innovation while helping champion healthcare access and equity for all.
Youll lead with purpose breaking down barriers to innovation ...Show more
Last updated: 30+ days ago • Promoted
Clinical Technologist
Mediclinic Group • Johannesburg, Gauteng, South Africa
Recruiter name : Nombulelo Florence Mpofu.Wits Donald Gordon Med Centre Parktown Johannesburg South Africa.To deliver safe comprehensive and quality patient care with specific reference to renal d...Show more
Last updated: 30+ days ago • Promoted
ASSISTANT DIRECTOR CLINICAL TECHNOLOGIST
Department of Health • Johannesburg, Gauteng, South Africa
ASSISTANT DIRECTOR CLINICAL TECHNOLOGIST.Package : R PER ANNUM (PLUS BENEFITS).Employer : Department of Health.Location : Chris Hani Baragwanath Academic Hospital.
An appropriate qualification that...Show more
Last updated: 30+ days ago • Promoted
Auditor
CG Recruitment • Johannesburg, South Africa
Auditor - Johannesburg (Fixed Term).Conduct audits, analyze financial data, develop plans.Degree in Accountancy, articles completed, SAICA / SAIPA affiliation.
Competitive package, growth opportunities.Show more
Last updated: 6 days ago • Promoted
Senior SAS Programmer - Clinical Trials Leader
Mms Holdings Inc • Gauteng, South Africa
A leading clinical research organization in South Africa is seeking a Senior Statistical Programmer to generate clinical trial data reports, lead programming teams, and ensure compliance with stand...Show more
Last updated: 21 hours ago • Promoted • New!
Clinical Trial Manager - IQVIA Biotech
IQVIA Biotech • Centurion, Gauteng, South Africa
Clinical Trial Manager - IQVIA Biotech.Clinical Trial Managers are an integral part of clinical trial delivery leading and working alongside clinical teams to improve patients lives by bringing new...Show more
Last updated: 30+ days ago • Promoted
Auditor / Junior Auditor
Isilumko Staffing (JHB) • Johannesburg, South Africa
Short Description / Purpose of Job.To conduct comprehensive audits on all relevant Supply Chain Procurement contracts and systems (specifically Road Logistics) in alignment with all applicable Gove...Show more
Last updated: 11 hours ago • Promoted • New!
Clinical Trial Manager IQVIA Biotech
IQVIA • Centurion, Gauteng, South Africa
Clinical Trial Manager - IQVIA Biotech.Please note : due to sponsor requirements for the role only candidates based in the listed location / s and with previous Global CTM experience will be considere...Show more
Last updated: 30+ days ago • Promoted
Business Development Manager (Healthcare Development)
Boardroom Appointments • Kempton Park, South Africa
Head of Healthcare Development.Business Development Identify and target new business opportunities within the Healthcare sector.
Responsible for achieving sales target through lead generation, prosp...Show more
Last updated: 30+ days ago • Promoted