Momentum Learnerships – Clinical Auditor

Website Momentum

Job Description:

Ensuring hospital claims are audited timeously and accurately as per our service level agreement, focusing on customer centricity and the quality of service rendered to the member within the scheme’s benefit design

Job Responsibilities:

  • Apply scheme rules, clinical policies, and protocols
  • Clinical support to provider network team and discussing identified trends to provider team
  • Assist with auth-claim matching queries
  • Review hospital network billing guidelines annually and feedback to the business
  • Ensure accurate savings is recorded according to pay codes and reason codes; reviewing automated monthly savings report
  • Review specific hospital claims for clinical appropriateness, treatment received, over usage of equipment/ materials, and consistency with billing rules
  • To identify hospital trends and claiming patterns with the objective of changing provider behavior and giving continuous feedback to the business
  • Liaise with the medical advisor if necessary
  • Review and maintain clinical auditing rules (CARM) annually
  • Action clinical auditing work and volumes timeously and within set service level agreement

Job Requirements:

  • Self-Motivation
  • Ability to work under pressure and meet deadlines
  • Target oriented
  • Attention to Details
  • Analytical thinking and investigative mind
  • Accurate and vigilant
  • Excellent problem solving skills
  • Conceptual thinking

Qualification & Experience:

  • Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife) is essential.
  • Diploma in Theatre Technique or ICU (or minimum 3 years relevant experience) is essential.
  • At least 5 years of post-graduate clinical experience is essential.
  • At least 3 years of Managed Care/Medical Aid industry experience is essential.
  • RPL course would be an advantage
  • Current registration with the SANC, on application.
  • Strong Oracle system knowledge and CARM rules is an advantage
  • Strong knowledge of PMB legislation, Clinical Coding (ICD 10, CPT & NHRPL), hospital and doctor’s billing guidelines is highly advantageous

Job Details:

Company: Momentum

Vacancy Type:  Full Time

Job Location: Durban, KwaZulu-Natal, SA

Application Deadline: N/A

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