Professional Nurse: Clinical Auditor

Location: Gqeberha, Eastern Cape, South Africa

Type: Permanent | Start Date: Jan/Feb 2026
Industry: Medical 

Role Purpose
Audit hospital claims accurately and timeously to reduce wastage, abuse and ensure alignment with authorisations, scheme rules, and clinical standards.

Minimum Requirements

• National Senior Certificate (Matric) — Essential
• Nursing Diploma or Degree — Essential
• Registered with the South African Nursing Council (SANC) — Essential
• 1–2 years private hospital nursing experience — Essential
• Exposure to clinical auditing — Highly advantageous
• MS 365 proficiency
• Clear criminal history

Key Responsibilities

• Audit allocated hospital claims according to KPIs and CMS requirements.
• Apply scheme rules, clinical protocols, and funding policies.
• Review claims for clinical appropriateness, treatment alignment, tariff application, and high-cost medication usage.
• Validate prosthesis usage and PMB funding.
• Record accurate notes on all audited journals.
• Finalise authorisations and refer complex queries to case managers.
• Provide clinical guidance to non-clinical claim auditors.
• Investigate, resolve, and escalate claim queries as required.
• Maintain professional stakeholder relationships.
• Identify opportunities to enhance cost effectiveness and operational efficiency.

Core Competencies

Attention to Detail | Teamwork | Time Management | Accountability |
Examining & Articulating Information | Upholding Standards

Note:
Shortlisted candidates will be expected to complete an online assessment and background verification checks.
If you have not been contacted within two weeks of submitting your CV, it is reasonable to deem your application unsuccessful.

Professional Nurse:  Clinical Auditor, with private hospital nursing background.