Clinical Auditor - Health Solutions

Momentum Health Solutions an entity of Momentum Metropolitan Holdings delivers sustainable integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.

Ensuring hospital claims are audited timeously and accurately as per our service level agreement focusing on customer centricity and the quality of service rendered to the member within the schemes benefit design.

• Registered Nurse with Degree or Diploma (General Psychiatric and Midwife) is essential.
• Current registration with the SANC on application.
• Diploma in Theatre Technique or ICU (or minimum 3 years relevant experience) is essential.
• RPL course would be an advantage.
• At least 5 years of postgraduate clinical experience is essential.
• At least 3 years of Managed Care/Medical Aid industry experience is essential.
• Strong knowledge of PMB legislation Clinical Coding (ICD 10 CPT & NHRPL) hospital and doctors billing guidelines is highly advantageous.
• Strong Oracle system knowledge and CARM rules is an advantage.

• Review specific hospital claims for clinical appropriateness treatment received over usage of equipment/ materials and consistency with billing rules.
• Apply scheme rules clinical policies and protocols.
• Liaise with the medical advisor if necessary.
• Review and maintain clinical auditing rules (CARM) annually.
• Review hospital network billing guidelines annually and feedback to the business.
• To identify hospital trends and claiming patterns with the objective of changing provider behavior and giving continuous feedback to the business.
• Clinical support to provider network team and discussing identified trends to provider team.
• Attend quarterly HRM operational meetings and feedback regarding trends and application of billing guidelines.
• Action clinical auditing work and volumes timeously and within set service level agreement.
• Assist with authclaim matching queries.
• Ensure accurate savings is recorded according to pay codes and reason codes; reviewing automated monthly savings report.

• Excellent problem solving skills
• Accurate and vigilant
• Target oriented
• Ability to work under pressure and meet deadlines
• Analytical thinking and investigative mind
• Conceptual thinking
• Attention to Details
• SelfMotivation
• Teamwork focused
• Analytical Thinking
• Good time management skills
• Quality orientated
• Trend management focus
• The ability to apply maintain and expand professional and technical knowledge in order to deliver a better service to customers and improve performance including sharing knowledge and experience with others.
• Excellent verbal Communication