A vacancy exists for a National Claims Review Manager based at Life Head Office, reporting to the National Patient Services Manager. The successful candidate will be responsible for managing the financial and clinical risks of the Business by reviewing claims, conducting audits of claims with regards to captured data on the LHC systems, billed items and contractual agreements. This person shall identify and highlight areas of non-compliance, manage, monitor, implement corrective action and assess the effectiveness of the corrective measures and report there on, to achieve the Life Healthcare objectives and strategy.

 

Critical Outputs

Implement a group strategy on Short-payment management to improve cash flow

 

Manage financial risk by

 

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.

Create online training tools to empower business on management of short payments.

 

Implement effective controls to ensure accurate billing by

 

Driving the accurate and timeous billing process to ensure Patient Services metric targets are achieved.

Ensures accurate application and interpretation of specialized wards criteria.

Engage with multidisciplinary team to improve billing accuracy: e.g. ward and theatre billing

 

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.

Audit hospital operational processes to

 

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 RSRT meetings and adhoc reporting.

Monitor effectiveness of implementation of action plans.

Audit the completeness and accuracy of claims e.g. full event details, coding, billing, etc.

Provides support for the management of clinical updates and rejections.

Ensuring compliance with the clinical code of conduct to ensure the accurate interpretation of a patient event.

Promote Effective quality management and customer care by

 

Continuous performance and quality Management.

Maintains client services principles to ensure client expectations are met.

 

Requirements

 

Degree/Diploma as a professional nurse with approximately 10 years post basic experience

Proven leadership and/or people management experience within healthcare.

Comprehensive understanding of the Life billing contracts and funder rules

Strong clinical competency skills and clinical coding, both ICD and CPT

Knowledge of electronic messaging

Knowledge of the hospital billing and claims process

Strong interpersonal and self-management skills

Computer proficiency (MS office)

Willing to travel

 

Competencies

 

Problem-solving, analysis and judgement

Attention to detail

Verbal and written communication skills

Influencing and Independence

Professional and technical proficiency

Research, planning, organizing implement, Monitor and

Reassess

Engaging diversity

Influencing and Negotiating Skills

Organisational awareness

Excellence orientation

Ethical behavior/integrity

Resilience

Knowledge of the hospital information system

Knowledge of LHC policies, practices, systems and procedures, protocols.

Building relationships and Networking

 

Interested candidates can send their CVs