Minimum Education: Nursing Qualification (Nursing Diploma as a registered nurse)

Minimum Experience: 3 to 5 years (previous clinical auditing experience in a managed healthcare environment is essential)

Duties and Requirements includes but is not limited to the following:

Knowledgeable of the Medical Schemes Act and Government Gazette on tariffs
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
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