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Clinical Auditor

Vacancy Details

Reference No.



Role Purpose 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 scheme's benefit design.


•Review specific hospital claims for clinically 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 behaviour 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 auth-claim matching queries

•Ensure accurate savings is recorded according to pay codes and reason codes; reviewing automated monthyl savings report


•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 post graduate clinical experience is essential.

•At least 3 years Managed Care/Medical Aid industry experience is essential.

•Strong knowledge of PMB legislation, Clinical Coding (ICD 10 , CPT & NHRPL), hospital and doctor's billing guidelines is highly advantageous

•Strong Oracle system knowledge and CARM rules is an advantage

Please note that if you havent received feedback within 2 weeks of submitting your application, consider it as unsuccessful 

Position Type


Work Level



Market Related


Pharmaceutical And Medical/Healthcare

Salary Type



Cost To Company

Affirmative Action


Geographic Location

Kwazulu Natal - Durban