CLINICAL AUDITOR HOSPITAL CLAIMS at MEDICAL SCHEME

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