Clinical Auditor

Recruiter:

Fusion Personnel

Job Ref:

JHB005285/Maris

Date posted:

Saturday, February 15, 2025

Location:

Johannesburg, South Africa

Salary:

540000 Annually

SUMMARY:
Well-established company in Johannesburg North seeks a Clinical Auditor with billing experience to join their team!

POSITION INFO:
Purpose of the Role:
Responsible for assessing and auditing hospital claims to ensure accurate billing, prevent abuse, and protect member funds while maintaining compliance with medical guidelines and regulations.

Requirements:

Qualifications: Nursing diploma (registered or enrolled nurse).
Experience: 3-5 years in clinical auditing or claims assessment within managed healthcare.
Technical Knowledge: Medical coding (ICD-10, CPT), hospital tariffs, billing rules, reconciliation of claims, and familiarity with IMED/Cubed systems.
Skills: Attention to detail, analytical thinking, professional communication, computer literacy, and numeracy.

Key Responsibilities:

Audit hospital accounts in accordance with billing regulations and clinical guidelines.
Identify non-chargeable items and overcharges.
Ensure hospital accounts align with authorizations on the system.
Investigate and resolve claims discrepancies.
Reconcile hospital accounts and liaise with external auditors on payment queries.
Negotiate discounts and credits with hospitals.
Capture and edit authorizations in the IMED system.
Provide clinical expertise and training within the organization.
Generate and submit weekly reports.
Handle queries from hospitals and members regarding claims and payments.

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