Key Performance Areas (KPAs):

• Ensure proper and appropriate medical treatment for members, safeguarding their funds while ensuring there’s no abuse by members or providers.
• Efficiently process claims within agreed service levels, ensuring accuracy and compliance with billing guidelines.

Job Key

Responsibilities:

• Vet hospital accounts according to the gazette guidelines.
• Use clinical guidelines and protocols when reviewing accounts.
• Liaise with teams and departments to ensure smooth processes.
• Audit captured accounts daily for accuracy.
• Align hospital accounts with system authorisations.
• Check for non-chargeable items as per gazette regulations.
• Evaluate accounts for technical correctness, using medical judgement.
• Reconcile hospital accounts efficiently.
• Respond to external auditors’ queries regarding account payments.
• Assist with mapping new tariffs, identifying and requesting them from IT.
• Provide weekly reports to management.
• Investigate claims based on daily reports.
• Capture authorisations on the IMED system.
• Handle member and hospital queries regarding account payments.
• Schedule weekly roster for clinical auditors.
• Negotiate discounts and credits with hospitals.
• Oversee the reversal of claims and provide feedback to service providers.

Clinical Auditor: Hospital Claims position available in Gauteng, Gauteng. This job position was posted by SD Recruitment (Pty) Ltd. The job has been posted as a char8000 ad on 2025-04-11 at 01:02:16 in the Medical category

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