Clinical Auditing Specialist - Discovery Limited

Key purpose

This position falls within the hospital risk unit and the successful candidate will be required to conduct clinical audits on hospital claims and events data, identify potential risk from inappropriate billing against industry rules and contractual agreements. Develop strategies to mitigate risks identified, apply control measures to manage hospital costs and ensure appropriate reporting to all stakeholders.

Key Outputs

The successful candidate will be responsible for but not limited to:

• Identifying potential risk areas in terms of hospital and pathology billing trends.
• Proactively engage with analysts in understanding risks to the scheme, log data requests and propose corrective measures
• Auditing of coding quality initiatives already identified within the operational areas (pre-auth and case management)
• Identify additional coding quality concerns not already addressed and come up with suggestions for further auditing and improvement initiatives

Auditing of a wide range of data:

• Hospital claims data
• Case management data
• Hospital contracts clinical data
• Reverse and record recoveries.
• Develop strategies to address inappropriate billing and propose control measures.
• Regular engagement with hospital groups and other stakeholders on inappropriate billing trends.
• Daily support to the hospital team and operations to ensure hospital-related initiatives are delivered on time.
• Influence the maintenance of benefits, input on escalated cases and review of bene-fits\protocols. 
• Providing prompt and accurate feedback to all stakeholders
• Internal presentations as a subject matter expect at various forums when necessary.
• Building a good relationship with internal and external stakeholders.

Competencies

The successful incumbent must be able to demonstrate the following competencies:

• Must be detail-oriented
• Ability to self-manage and work within a team simultaneously
• Stakeholder interaction on a professional level with internal and external clients for whom we conduct audits
• Ability to express opinions, information and key points of an argument clearly
• Monitors performance against deadlines and milestones
• Sets high standards for quality and quantity
• Makes rational judgements from the available information and analysis
• Takes initiative and works under own direction
• Focuses on customer needs and satisfaction
• Upholds ethics and values; demonstrates integrity
• Flexible in handling multiple projects simultaneously

Qualifications & Work Experience

• Matric/ Matric equivalent 
• Clinical Qualification
• Working knowledge of Outlook, Excel, Word and PowerPoint computer packages is essential 
• Must have completed coding training at least to an intermediate level, with a view towards undertaking an advanced local accreditation course (thus must be willing to study further)
• Previous auditing experience 
• ICD-10, (CCSA.) coding and other coding schemas experience
• Case management experience
• A good understanding of industry coding processes and industry forums in which Discovery and the Coding Unit participate
• Discovery claims and product experience
• Bill audit review experience