CLINICAL AUDITOR HOSPITAL CLAIMS at MEDICAL SCHEME
Che Leigh Personnel Consultants
- Undisclosed
- Permanent Specialist position
-
Bryanston
- Posted 26 May 2024 by Che Leigh Personnel Consultants
- Expires in 18 days
-
Job 2568775
About the position
Key Performance Areas (KPAs)
- Ensuring that members get proper & appropriate medical treatment in accordance with the billing guidelines, while also protecting members' funds by ensuring that there is no abuse by members or providers
- Ensuring that all the claims & duties are performed within the agreed service levels with providers and that claims are efficiently and accurately processed.
Responsibilities
- Vet hospital accounts under the guidance of the gazette
- Use clinical guidelines and protocols when vetting accounts
- Liaise with other members of the team and other departments
- Daily auditing of captured accounts
- Align hospital accounts with authorisation on system
- Checking accounts for non- chargeable items - as per gazette
- Evaluation of accounts for technical correctness using sound medical judgement
- Reconcile hospital accounts
- Deal with external auditors' queries regarding payment of hospital accounts
- Involved with mapping of new tariffs, by identifying them & sending requests to IT capturing/editing/auditing
- Provide weekly reports to management
- Investigate claims against daily reports
- Capture authorisations on the IMED system
- Handle member /hospital queries regarding hospital accounts payment
- Schedule the weekly roster for the clinical auditors
- Work with other healthcare personnel within the organisation
- Provide clinical expertise within the organisation where required
- Negotiation of discounts and credits with hospitals
- Reversal of claims and provide feedback to service providers
- Training of staff within the organisation
Qualifications
Registered or Enrolled Nurse
Experience with Tariff and Nappi Codes, Modifiers, Practice Types, ICD 10 Codes
3 -5 years experience in Clinical Auditing
Desired Skills:
- Registered or Enrolled Nurse
- Clinical Auditing of Hospital Claims
Che Leigh Personnel Consultants
About the agency
A professional agency with over 20 years experience in the Recruitment industry. We place people across the board with a strong emphasis in Healthcare, Financial Services and Legal.
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