A vacancy exists for a Bill Auditor based at Life Flora Hospital, reporting to Gail Bunting, Patient Services Manager. The successful candidate will be responsible for managing the financial and clinical risks by reviewing claims, conducting audits of patient records and 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, in support of the company objectives and strategy.

Critical Outputs
Grow our business through improved utilisation of assets and enhanced return on investment

Implementation, facilitation and sustainment of Patient Services initiatives / strategy projects.
Manage compliance with all Policies & Work Procedures to minimize clinical, Reputational and financial Risk.
Manage the working capital KPI’s related to IDSO’s, repricing errors, rejections and clawback on short payment management.
Champion change, for the implementation of new growth strategies within the hospital
Participating in and developing action plans within the risk management team.
Liaison with Hospital Manco teams on funder requirements where necessary.
Efficiency resulting in the delivery of improved cost-effective care

Drive effective application and correct interpretation of all types of risk sharing reimbursement tariffs and contracts, funder rules and PMB’s (where applicable)
Manage accuracy of accounts to Funders and implement corrective actions where identify.
Ensure that the Life Healthcare Contracts are applied accurately to enable risk management.
Effective auditing of hospital operational processes:
Evaluate data accuracy, identify deviations, implement corrective actions and monitor improvement and effectiveness of action plans.
Analyse and report on trends and influence the responsible parties to drive improvements on focus areas.
Audit the completeness and accuracy of claims e.g. Data Governance, full event details, coding, billing, etc.
Provide support for the management of clinical updates, repricing errors and rejections.
Ensure compliance with the clinical code of conduct to ensure the accurate interpretation of a patient event.
Reporting/monitoring/assisting with of all matters relating to case management:
Authorisation disputes
Internal DSO
Claim rejections
Claim disputes/short payments
PMB disputes.
Repricing Errors
Implement and monitor the Patient Services workflow processes and available management reports related to the patient journey.
Engagement with funders regarding disputes with regards to contractual agreements.
RSRT and DRG profit/loss analysis and reporting.
Deliver high-quality care through continuous improvement in patient experience and clinical outcomes

Comply with hospital closure of any non-compliance identified in the audits, review risks and ensure immediate closure of critical non-conformances.
Support the PSM to manage and evaluate the effectiveness (IDSO’s) of agreed SLA’s (service level agreements) between the different functional areas – evaluate for effectiveness and suggest improvements to the process for the next financial year period (e.g., internal DSO’s).
Report all non-conformances and support PSM to manage by performing root case analysis, trending and evaluation.
Ensure targets achieved as per PS scorecard
Assist with Quality Improvement where gaps have been identified from audits/complaints/trends.
Management of Data Quality through Data Governance processes.
Data Management process for the unit includes POPI/PAIA.
Records management process to ensures the secure and compliant handling of documents throughout their lifecycle, including scanning, controlled destruction, long-term archiving, and adherence to regulatory and organisational standards.
Ensure long-term sustainability through appropriate investment and minimising our environmental impact while positively impacting the communities

Management of stakeholder relationships internally and externally to promote strategy and efficiency by
Develop and maintain collaborative relationships with internal stakeholders to achieve objectives.
Manage Continuous Learning, optimise performance and Promote Quality Management Systems.
Manage Patient Experience to ensure expectations are exceeded/met.

Requirements

Nursing Qualification, Professional Nurse with at least three years’ experience, with proven case manager and clinical coding experience of at least 3 – 5 years.
Current SANC registration appropriate to relevant Medical Qualification
Knowledge of hospital patient services and billing processes and private hospital industry and practices
Comprehensive knowledge and understanding of CPT & ICD coding
Knowledge of Funder contracts, scheme rules, exclusions and benefits
Computer proficiency
Competency of related legislation e.g. National Health Act, Medical Schemes Act with regulations, Mental Healthcare Act.

Competencies

Problem-solving, analysis and judgement
Attention to detail
Verbal and written communication skills and presentation skills
Influencing and Independence
Professional and technical proficiency
Planning and organising
Process orientation
Interpersonal and relationship building skills
Organisational awareness
Excellence orientation
Ethical behavior/integrity
Resilience
Drive and energy
Self-management
Personal integrity

Please send your resume/CV