National Clinical Review Manager

Life Healthcare Head Office
National Clinical Review Manager

A vacancy exists for a Clinical Review Manager based at Life Head Office, reporting to the National Patient Services Manager. The successful candidate will be responsible for managing the financial and clinical risks of the Business by reviewing claims, conducting audits of claims with regards to captured data on the LHC systems, billed items and contractual agreements. This person shall identify and highlight areas of non-compliance, manage, monitor, implement corrective action and assess the effectiveness of the corrective measures and report there on, to achieve the Life Healthcare objectives and strategy.

Critical Outputs
  1. Implement a national strategy to optimize revenue cycle processes, identifying and addressing potential risks related to case management short-payments, clinical coding, and billing inaccuracies.
  2. Create innovative solutions, developing and implementing business strategies to enhance revenue cycle performance, ensuring compliance with industry standards and regulations.
  3. Empower the business to use data driven insights by implementing advanced analytics to identify trends, patterns, and opportunities for improvement and driving informed decision-making to maximize revenue and minimize risks.
  4. Foster collaborative relationships with cross-functional teams in Patient Services, Nursing, Pharmacy, Procurements including case management, clinical coding, finance, and operations, to achieve seamless revenue cycle operations. 
  5. Establish and monitor key performance indicators to track success and address any deviations promptly and ensuring continuous improvement.
  6. Manage financial risk by
  • 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. 
  1. Create online training tools to empower business on management of operational risks in Patient Services e.g. case management related short payments, repricing errors, claim rejections.
  2. Implement effective controls to ensure accurate billing by
  • Driving the accurate and timeous billing process to ensure Patient Services metric targets are achieved.
  • Ensures accurate application and interpretation of specialized wards criteria. 
  1. Champion the national implementation of RSRT meetings with multidisciplinary team engagement to improve billing accuracy e.g. ward and theatre billing and related risk management.
  2. 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.
  1. Audit hospital operational processes to
  • 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 RSRT meetings and adhoc reporting.
  • Monitor effectiveness of implementation of action plans.
  • Audit the completeness and accuracy of claims e.g. full event details, coding, billing, etc.
  • Provides support for the management of clinical updates and rejections.
  • Ensuring compliance with the clinical code of conduct to ensure the accurate interpretation of a patient event.
  1. Promote Effective quality management and customer care by
  • Continuous performance and quality management.
  • Maintains Patient Services principles to ensure stakeholder expectations are met.
  1. Manage process reviews and audits and agree terms of reference for External Audits in Patient Services e.g., Revenue Audits and Clinical coding audits.
  • Degree/Diploma as a professional nurse with approximately 10 years post basic experience
  • Proven leadership and/or people management experience within healthcare.
  • Comprehensive understanding of the Life billing contracts and funder rules.
  • Comprehensive knowledge of the Patient Services working procedures, policies and operational processes including BI dashboards and reports.
  • Strong clinical competency and acumen
  • Clinical coding competency in ICD-10 and CCSA/CPT®
  • Knowledge of electronic messaging
  • Knowledge of the hospital billing and claims process.
  • Strong interpersonal and self-management skills
  • Computer proficiency (MS Office, Teams etc)
  • Willing to travel.
  • Problem-solving, analysis and judgement
  • Attention to detail.
  • Verbal and written communication skills
  • Influencing and Independence
  • Professional and technical proficiency
  • Research, planning, organizing implement, Monitor and Reassess
  • Engaging diversity
  • Influencing and Negotiating Skills
  • Organisational awareness
  • Excellence orientation
  • Ethical behavior/integrity
  • Resilience
  • Knowledge of the hospital information system
  • Knowledge of LHC policies, practices, systems and procedures, protocols.
  • Building relationships and Networking
Closing date
Friday, April 12, 2024

Internal applicants - Before making an application, you are requested to discuss your application with your line manager. External candidates will also be considered.

Explore our vacancies and find the right opportunity for you. Download the application form and email to the relevant contact person specified in the job advertisement.

Life Healthcare is an Equal Opportunity Employer. 

Thank you for your interest in this opportunity. Kindly note that only shortlisted candidates will be contacted.  Applicants who have not been contacted within two weeks of the closing date of this advert, should consider their application as unsuccessful.



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