Job Description

QUALIFICATIONS AND EXPERIENCE:

• Matric essential.
• Nursing Diploma or Degree essential.
• Minimum of 2 yearsxe2x80x99 private hospital nursing experience.
• Minimum of 1 yearsxe2x80x99 administrative exposure to the medical scheme industry.
• Minimum of 1 yearsxe2x80x99 exposure to hospital claim processes, billings and tariffs.
• Must be registered with SANC (South African Nursing Council) as a Registered Nurse.
• Excellent understanding of the Medical Schemes Act, as well as PMB legislation.
• Sound knowledge of ICD-10 and procedural coding.
• MS Office proficiency essential.
• Previous exposure to clinical auditing is highly advantageous
• Open to SA citizens with a clear criminal and credit history.
• Valid unendorsed Driverxe2x80x99s License with own vehicle (advantageous).

ROLES AND RESPONSIBILITIES:
To ensure that hospital claims are audited timeously and accurately with the focus on reducing wastage and abuse. To ensure claims processed in accordance with that which the scheme has authorised.
Performance areas include, but are not limited to:

• Review hospital claims for clinical appropriateness, treatment authorised, over-usage of equipment/materials, application of billing rules and high-cost medication appropriateness.
• Apply scheme rules, clinical policies and protocols to funding.
• Action allocated hospital claims for audit within department KPIs and CMS requirements for claims payment.
• Ensure accurate notes are made for all journals actioned on claims audited.
• Assess prosthesis for PMB funding when benefits are exceeded or if there is no benefit.
• Ensure accurate completion of authorisations on claim finalisation.
• Refer LOC/ LOS / item or drug approval queries to case managers for resolution.
• Act as clinical support to non-clinical hospital claim auditors in terms of hospital tariff applications and clinical guidance (e.g. procedures, devices and drug utilisation).
• Survey claims for correct application of tariff and refer discrepancies to the claim team.
• Review retrospective claim approvals and send journal instructions for additional payments to the claims team.

CUSTOMER SERVICE

• Investigate hospital claim queries within the agreed service level and ensure that the relevant stakeholder receives timeous feedback.
• Escalate queries to the relevant team or stakeholder.
• Provide accurate information and advice to stakeholders to ensure that they receive the appropriate service.
• Resolve claim queries accurately and timeously.
• Build and maintain relationships with internal and external stakeholders.
• Reduce claim rejections to ensure members are not held liable for unnecessary costs.

PEOPLE

• Build strong relationships through expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.

FINANCE

• Identify opportunities to enhance cost effectiveness and increase operational efficiency.
• Manage financial and other company resources under your control with due respect.
• Provide input into the risk identification processes and communicate recommendations in the appropriate forum.

IMPORTANT ATTRIBUTES:

• Attention to detail, goal orientated and a desire to achieve your objectives.
• Teamwork.
• Examining information (interrogate claims data).
• Articulating information.
• Upholding standards.
• Accountability.
• Attention to detail.
• Time management.
• Highly organised, good at multi-tasking and able to deal with people at all levels.

Location: Port Elizabeth (no relocation assistance available for out-of-town applicants)
Profile: Healthcare
Career Level: 2+ years.
Employment: Permanent, full-time
E.E. / Non-EE: Preference will be given to AC&I applicants in line with the company's Employment Equity Plan
Working Hours: Monday to Friday. 08H00 -17H00
Remuneration: Market related basic + Benefits and 13th cheque

Short listed candidates may be expected to complete and pass assessments before moving to the next stage of the recruitment process.
Should you not be contacted within two weeks, please consider your application unsuccessful.