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.

What you’re going to do

  • 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 monthly savings report;

What you’ll need:

  • Registered Nurse and/or midwife essential
  • Diploma in Theatre Technique or ICU (or relevant experience)
  • RPL course would be an advantage
  • At least 5 years post graduate clinical experience
  • At least 3 years industry experience
  • Strong knowledge of PMB legislation is an advantage
  • Understanding of hospital billing guidelines is an advantage
  • Strong Oracle system knowledge and CARM rules is an advantage

What competencies you’ll require

  • Excellent problem solving skills
  • Accurate and vigilant
  • Target oriented
  • Ability to work under pressure and meet deadlines
  • Analytical thinking and investigative mind
  • Conceptual thinking
  • Attention to Details
  • Self-Motivation
  • Teamwork focused
  • Analytical Thinking
  • Good time management skills
  • Quality orientated
  • Trend management focus
  • The ability to apply, maintain and expand professional and technical knowledge in order to deliver a better service to customers and improve performance, including sharing knowledge and experience with others
  • Excellent verbal Communication

Desired Skills:

  • Auditing

About The Employer:


Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.

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