Clinical Review Specialist x9

Function

Other

Facility

Cape Town Regional Office

Position

Clinical Review Specialist x9

Introduction

Vacancies exist for Nine Clinical Review Specialist based in Cape Town Regional Office, reporting to the National Clinical Review Manager. The successful candidate will manage the financial, reputational and clinical risk of the business units by reviewing claims, conducting audits of patient records and claims regarding captured data on the LHC systems, billed items and contractual agreements. This person shall identify and highlight areas of non – compliances, manage, monitor, implement corrective actions and assess the effectiveness of corrective measures and report there on, to achieve the Life Healthcare objectives and strategy.

Critical Outputs

Management of financial risk by

• The interpretation and application of different reimbursement contracts within the business units
• RSRT and DRG profit/loss analysis and reporting
• Engagement with funders regarding disputes with regards to contractual agreements
• Analyse data trends relating to rejections and short payments etc.
• Verification of clinical coding as per policies and procedures
• Preparing and ensuring sound audit compliances to achieve optimum business ethics
• Participating and developing action plans within the risk management team
• Liaison with doctors on funder requirements when necessary
• Interpretation and implementation of scheme benefit rules
• Reducing and managing the risk associated with RSRT’s by making recommendations regarding patient-based data.

Ensure effective and accurate billing by

• Drive the accurate and timeous billing process to ensure Patient Services metric targets are achieved.
• Ensures accurate application and interpretation of specialised ward criteria

Reporting/Monitoring/Assisting with all matters related to

• Short payments disputes
• Authorisation disputes
• Claim disputes
• PMB disputes

Management of relationships with stakeholders internally and externally to promote strategy and efficiency by

• Funder liaison
• Contractual obligations
• Develop and maintain sound relationships with internal customers to achieve co-operation and compliance with audit processes

Effective auditing of hospital operational processes

• Evaluate data accuracy to identify deviations and make recommendations for corrective action, implement and monitor the same
• Analyse trends to identify deviations, report on and influence the responsible persons through presentations and discussion in monthly meetings and adhoc reporting
• Monitor effectiveness of implementation of action plans
• Audit completeness and accuracy of claims, e.g. full event details, coding, billing etc.
• Ensuring compliance with the clinical code of conduct to ensure the accurate interpretation of a patient event

Effective quality management and customer care by

• Continuous performance and quality Management.
• Maintains client services principles to ensure client expectations are met

Requirements

• Nursing Qualification, preferably Professional Nurse with at least three years’ experience or Enrolled Nurse with proved case manager and clinical coding experience of at least 3-5 years.
• Current SANC registration
• 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