Vacancies exist for Nine Clinical Review Specialist based in Cape Town Regional Office, reporting to the National Clinical Review Manager. The successful candidate will manage the financial, reputational and clinical risk of the business units by reviewing claims, conducting audits of patient records and claims regarding captured data on the LHC systems, billed items and contractual agreements. This person shall identify and highlight areas of non – compliances, manage, monitor, implement corrective actions and assess the effectiveness of corrective measures and report there on, to achieve the Life Healthcare objectives and strategy.

Critical Outputs
Management of financial risk by

The interpretation and application of different reimbursement contracts within the business units
RSRT and DRG profit/loss analysis and reporting
Engagement with funders regarding disputes with regards to contractual agreements
Analyse data trends relating to rejections and short payments etc.
Verification of clinical coding as per policies and procedures
Preparing and ensuring sound audit compliances to achieve optimum business ethics
Participating and developing action plans within the risk management team
Liaison with doctors on funder requirements when necessary
Interpretation and implementation of scheme benefit rules
Reducing and managing the risk associated with RSRT’s by making recommendations regarding patient-based data.
Ensure effective and accurate billing by

Drive the accurate and timeous billing process to ensure Patient Services metric targets are achieved.
Ensures accurate application and interpretation of specialised ward criteria
Reporting/Monitoring/Assisting with all matters related to

Short payments disputes
Authorisation disputes
Claim disputes
PMB disputes
Management of relationships with stakeholders internally and externally to promote strategy and efficiency by

Funder liaison
Contractual obligations
Develop and maintain sound relationships with internal customers to achieve co-operation and compliance with audit processes
Effective auditing of hospital operational processes

Evaluate data accuracy to identify deviations and make recommendations for corrective action, implement and monitor the same
Analyse trends to identify deviations, report on and influence the responsible persons through presentations and discussion in monthly meetings and adhoc reporting
Monitor effectiveness of implementation of action plans
Audit completeness and accuracy of claims, e.g. full event details, coding, billing etc.
Ensuring compliance with the clinical code of conduct to ensure the accurate interpretation of a patient event
Effective quality management and customer care by

Continuous performance and quality Management.
Maintains client services principles to ensure client expectations are met

Requirements

Nursing Qualification, preferably Professional Nurse with at least three years’ experience or Enrolled Nurse with proved case manager and clinical coding experience of at least 3-5 years.
Current SANC registration
Knowledge of hospital patient services and billing processes
Knowledge and understanding of CPT & ICD coding
Knowledge of Funder contracts, scheme rules, exclusions and benefits
Understanding of private hospital industry and practices
Computer proficiency
Valid driver’s license

Competencies

Attention to detail
Problem-solving, analysis and judgement
Resilience
Engaging diversity
Verbal & written communication skills
Professional and technical proficiency
Interpersonal and relationship building skill
Customer responsiveness
Organisational awareness
Influencing skills
Action orientation
Excellence orientation
Ethical behaviour
Drive and energy

Please send your resume/CV