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T

Specialist Clinical Auditor

THE RX Group Of Companies
6 days ago
Full-time
On-site
Pretoria, South Africa
Auditing, Regulatory, Quality, and Compliance

Introduction

 

The Clinical Auditor plays a pivotal role in ensuring healthcare providers, including hospitals and other medical facilities, adhere to relevant billing, coding, and clinical protocols. The incumbent routinely conducts clinical account audits to verify compliance with set standards, identify areas for improvement, and recommend enhancements to clinical practices. These recommendations may involve process or procedural changes or the adoption of new healthcare technologies or equipment, ultimately aiming to deliver optimal patient care.

Duties & Responsibilities

 

  • Conducting audits of hospital accounts within agreed SLAs for contracted medical schemes
  • Communicating with healthcare service providers regarding disputed items
  • Collaborating with Medical Advisors and Clinical Managers for clinical guidance
  • Identifying and reporting trends related to fraud, waste, and abuse
  • Applying authorisation criteria: Level of Care, Rand amount, clinical protocols, coding accuracy, payment instructions, limits, benefits, and co-payments where applicable
  • Enforcing tariff criteria, including PMB legislation, tariff guidelines, and billing policies
  • Ensuring billing aligns with client-specific agreements and hospital group policies

 

  • Validating that charges are valid, justified, and clinically appropriate during audits
  • Reviewing medical records for completeness, accuracy, and quality of patient documentation
  • Researching new healthcare technologies, treatments, or procedures for safety and efficacy assessments
  • Preparing comprehensive reports with findings and recommendations for process improvement
  • Ensuring hospital and clinic staff adhere to organisational policies and procedures

Desired Experience & Qualification

 

  • Registered Nurse (RN)
  • Valid registration with the South African Nursing Council (SANC)
  • Minimum of 3-5 years’ experience in a similar role within managed healthcare or medical scheme environments
  • At least 3 years’ experience working within a private hospital’s accounts department, responsible for billing and account management with medical schemes
  • In-depth knowledge of the South African healthcare industry, legislation, and current coding standards (ICD-10, CPT-4, NRPL, PMB conditions, and clinical protocols)
  • Strong clinical knowledge of hospital pre-authorisation, case management, and billing processes (including Length of Stay and Level of Care assessments)
  • Outcome-focused with the ability to manage multiple priorities effectively
  • Excellent verbal and written communication skills
  • Ability to liaise confidently with external stakeholders (clinicians, healthcare facilities) and internal colleagues across service areas
  • Proven ability to handle emotionally charged and stressful situations professionally
  • Self-motivated with the ability to work independently