Position: Clinical Auditor
Location: Sandton
Industry: Managed Care
REF: MCP:JHB-CA
A leading organisation in the healthcare funding sector seeks to employ Clinical Auditors (x4) to strengthen the accuracy, integrity, and quality of hospital claims management.
Role Overview
The role focuses on auditing hospital claims for clinical appropriateness, coding accuracy, compliance with benefit design, and early identification of fraud, waste, and abuse. You’ll work closely with clinical, provider, and operational teams to improve quality, cost‑efficiency, and service outcomes.
What You’ll Do
- Audit hospital claims for clinical validity, coding accuracy, and alignment with billing rules.
- Apply scheme rules, clinical policies, and protocols to determine claim eligibility.
- Analyse claims trends and provide insights to influence provider behaviour and improve processes.
- Update and maintain clinical auditing rules and billing guidelines.
- Collaborate with medical advisors and provider network teams on complex cases.
- Participate in training, knowledge‑sharing, and continuous improvement initiatives.
- Support financial risk management through accurate savings recording and data‑driven insights.
Requirements:
- Registered Nurse or Allied Health Professional (SANC registration essential).
- 5+ years’ experience in the managed care environment.
- Coding knowledge (ICD‑10, CPT, DRG) advantageous.
- Strong understanding of medical terminology, treatment protocols, PMBs, billing practices, and reimbursement models.
- Experience with clinical auditing methodologies, claims systems, and data analysis tools.
- Knowledge of CARM rules and hospital billing guidelines.
- Detailed WORD CV please
- Copy of Council Registration
- Copy of Degree