Specialist Clinical Auditor

About the role

The Clinical Auditor ensures that hospitals and other medical facilities comply with billing, coding and clinical protocols. By conducting detailed account audits, the role helps improve patient care and reduce fraud, waste and abuse.

Key responsibilities

• Conduct audits of hospital accounts within agreed SLAs for contracted medical schemes.
• Communicate with healthcare service providers regarding disputed items and apply authorisation criteria.
• Identify and report trends related to fraud, waste and abuse, enforcing tariff and billing policies.
• Validate that charges are clinically appropriate and review medical records for completeness and accuracy.
• Research new healthcare technologies, treatments or procedures for safety and efficacy assessments.
• Prepare comprehensive reports with findings and recommendations for process improvement.

Required profile

• Registered Nurse with a valid South African Nursing Council registration.
• Minimum 3‑5 years’ experience in managed healthcare or medical scheme environments.
• At least 3 years’ experience in a private hospital’s accounts department handling billing and account management.
• In‑depth knowledge of South African healthcare legislation and current coding standards.
• Strong clinical knowledge of pre‑authorisation, case management and billing processes (Length of Stay, Level of Care assessments).
• Excellent verbal and written communication skills and ability to handle emotionally charged situations professionally.

Required skills

• ICD‑10 coding
• CPT‑4 coding
• NRPL coding
• PMB conditions and tariff guidelines
• Clinical protocols and coding accuracy
• Hospital billing policies and pre‑authorisation processes