Clinical Auditor

Job Description

Momentum Metropolitan Holdings is looking for Clinical Auditors to ensure accurate and timely auditing of claims, minimizing wastage and abuse. You will apply clinical expertise to assess claims, ensure compliance with regulations, and support efficient claims processing. This role is critical in maintaining quality standards and fostering trust with clients and stakeholders across multiple locations in South Africa.

Requirements

• Matric/Grade 12
• Bachelor’s degree or equivalent in Nursing, Health Information Management, Health Administration, Healthcare Management, or related field (advantageous)
• 3 - 5 years of clinical experience in a healthcare environment
• Previous exposure to clinical auditing (advantageous)
• Proficiency in MS Office / Office 365
• Registered nurse with the South African Nursing Council (SANC) (advantageous)
• Familiarity with medical coding systems (e.g., ICD-10) and accurate application for coding diagnoses, procedures, and services
• Understanding of healthcare regulations, laws, compliance requirements, and medical coding guidelines
• Proficiency in reviewing and interpreting medical documentation
• Knowledge of medical terminology, diagnoses, procedures, treatment protocols, and healthcare benefit plans
• Understanding of billing practices, fee schedules, reimbursement methodologies, and 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, claims management systems, and auditing software
• Understanding of Prescribed Minimum Benefits (PMB) legislation and its implications
• Knowledge of Clinical Auditing, Risk Management, and Clinical and Billing rules

Responsibilities

• Apply scheme rules, clinical policies, and protocols to support funding of claims
• Action allocated claims for audit within department KPIs and CMS requirements
• Ensure accurate notes are made for all journals actioned on claims audited
• Assess PMB funding in collaboration with Managed Care Organisation and approved PMB manual
• Act as clinical support to non-clinical Claim Auditors for billing and funding rules
• Survey claims for correct application of tariff and refer discrepancies to the relevant team
• Review retrospective claim approvals and refer for additional clinical information to Medical Advisors
• Review claims for clinical appropriateness
• Analyze hospital claims data and trends to identify patterns and behavior, providing feedback to influence provider behavior
• Implement changes to improve claims management processes
• Build and maintain relationships with clients and stakeholders
• Deliver on service level agreements to manage client expectations
• Make recommendations to improve client service and fair treatment of clients
• Participate in a culture of rewarding relationships, feedback, and exceptional client service
• Monitor turnaround times and quality standards, resolving issues to enhance client service delivery
• Drive client service delivery goal achievement in line with predefined standards
• Manage client query processes, ensuring accurate resolution and process improvement
• Build strong relationships through specialist know-how and leadership
• Continuously develop expertise in industry and subject matter
• Positively influence and manage change, offering specialist support
• Contribute to continuous innovation through sharing and implementing new ideas
• Participate in a culture of work-centric thinking, productivity, and quality management
• Take ownership for driving career development
• Contribute to area-specific budget development to minimize expenditure
• Identify solutions to enhance cost effectiveness and operational efficiency
• Implement and provide input into governance processes, systems, and legislation
• Escalate unresolved policy and governance compliance issues
• Provide input into risk identification processes and communicate recommendations