Clinical Review Specialist Team Leader

Function

Other

Facility

Cape Town Regional Office

Position

Clinical Review Specialist Team Leader

Introduction

A vacancy exists for a Clinical Review Specialist Team Leader based in Cape Town Regional Office, reporting to the National Clinical Review Manager. The successful candidate will provide strategic oversight and leadership in the management of financial and clinical risks within the business. This role is responsible for managing a clinical review team to ensure the effective identification, analysis, and mitigation of clinical and financial risks, while ensuring billing accuracy, contractual compliance, and adherence to regulatory requirements. The successful candidate will play a key role in driving operational excellence, influencing stakeholders, and ensuring high-quality, compliant outputs aligned to Life Healthcare’s strategic objectives.

Critical Outputs

Leadership & Team Management

• Lead, coach, and develop a high-performing clinical review team.
• Allocate work, monitor productivity, and ensure delivery against KPIs and audit targets.
• Foster a culture of accountability, quality, and continuous improvement.
• Provide technical guidance on complex audits, coding validation, and risk identification.

Audit Oversight, Risk & Compliance Management

• Oversee auditing of patient accounts, clinical coding accuracy, and billing compliance.
• Ensure verification of clinical coding in line with policies, procedures, and industry standards.
• Ensure audit completeness and accuracy of claims (event details, coding, billing).
• Identify risks, trends, and non-compliance, and oversee implementation of corrective action plans.
• Ensure sound audit governance and compliance practices to uphold ethical business standards.
• Participate in risk management forums and contribute to the development and monitoring of action plans.
• Monitor effectiveness of implemented corrective actions and drive continuous improvement.

Operational Excellence & Financial Performance

• Oversee the interpretation and application of reimbursement contracts, scheme benefit rules, and specialised ward criteria.
• Manage and reduce financial risk through RSRT (Risk Sharing Reimbursement Tariff) and DRG (Diagnosis related grouping) profit/loss analysis and reporting.
• Analyse data trends relating to rejections, short payments, and billing discrepancies to inform decision-making.
• Drive accurate and timeous billing processes to achieve Patient Services metric targets.
• Reduce and manage risk associated with RSRTs through data-driven recommendations and insights

Stakeholder Engagement & Dispute Resolution

• Manage relationships with internal and external stakeholders to support operational efficiency and strategy.
• Engage with funders on disputes relating to claims, authorisations, PMBs, short payments, and contractual interpretations.
• Liaise with doctors and clinical stakeholders on funder requirements and billing practices where required.
• Promote collaboration and ensure alignment with contractual obligations and audit processes across departments.

Reporting, Monitoring & Insights

• Oversee and validate audit reports, trend analyses, and performance metrics.
• Analyse deviations, identify root causes, and influence corrective actions through structured reporting and presentations.
• Provide insights on financial leakage, compliance risks, and operational inefficiencies.
• Support effective monitoring of dispute resolution processes and outcomes.

Quality Management & Customer Focus

• Drive continuous performance and quality management within the team.
• Ensure adherence to clinical codes of conduct and patient-centric service delivery standards.
• Maintain client service excellence by ensuring expectations of internal and external stakeholders are consistently met.
• Contribute to quality improvement initiatives and ensure compliance with organisational and regulatory standards.

Requirements

• Nursing Qualification, preferably Professional Nurse with at least 5 years’ experience
• Proven case manager and clinical coding experience of at least 5 years.
• Current registration with the relevant professional/regulatory body (South African Nursing Council)
• Knowledge of hospital patient services and billing processes
• Knowledge and understanding of CPT & ICD coding
• Knowledge of Funder contracts, scheme rules, exclusions and benefits
• Understanding of private hospital industry and practices
• Computer proficiency
• Valid driver’s license

Competencies

• Attention to detail
• Problem-solving, analysis and judgement
• Resilience
• Engaging diversity
• Verbal & written communication skills
• Professional and technical proficiency
• Interpersonal and relationship building skill
• Customer responsiveness
• Organisational awareness
• Influencing skills
• Action orientation
• Excellence orientation
• Ethical behaviour
• Drive and energy

Email

careers@lifehealthcare.co.za

Closing date

Friday, June 12, 2026