Senior Clinical Claims Reviewer

SUMMARY:
Senior Clinical Claims Reviewer

POSITION INFO:
Core Purpose At Medihelp, we live our values daily - excellence, compassion, collaboration, and transparency - to make a real difference in the lives of our members . We're looking for someone who lives these values through their mindset, work ethic, and interactions with others. The Senior Clinical Claims Reviewer primarily audits hospital, private nursing, and wound care claims using knowledge of hospital contracts and negotiated tariff structures. REQUIREMENTS Grade 12 and an Enrolled Nurse or Nursing Assistant qualification Current registration with the SANC At least two years' experience in clinical account review and auditing, preferably in a hospital or managed care environment Comprehensive knowledge of the Medical Scheme Act, with sound knowledge of ICD-10, CPT-4 & RPL codes Knowledge of the Scheme Rules, Scheme Tariffs and exclusions KEY COMPETENCIES Excellent written and verbal communication skills Proficiency in Microsoft Office Customer-focused approach Strong negotiation skills Ability to work independently and collaboratively Ability to build positive working relationships• Sound decision-making skills Join a team where our values guide everything we do - from how we work together to how we serve our members .