As the Prosthesis Clinical Analyst - you will ensure hospital cost savings as a result of developing and implementing claims leakage strategies, system rule improvements and controls; undertaking hospital contract compliance activities (including the conduct and management of onsite and desktop provider audits); and validating provider billing and coding practices.
**How will I help?**
Key accountabilities include:
- Initiate, manage and finalise hospital, clinical, provider, and member profiling reviews within an agreed annual work program.
- Arrange and conduct regular onsite and desktop provider audits, manage end to end processes including follow up and financial management of incorrect billing
- Review the specific detail of hospital claims to advise where there are incorrect or inappropriate coding/ billing practices
- Validate provider initiated DRG review requests based on coding and documentation analysis
- Provide clinical/coding standards advice on statistical reports produced by Data and Claims Analysts to determine if further investigation and action is warranted.
- Initiate, write, develop, and continually improve relevant data reports to identify areas of actual and potential claims leakage based on Bupa Hospital and Medical contracts
**What's in it for me?**
As well as a competitive salary, a range of Bupa benefits and flexible working/ work from home arrangements, you'll be challenged and encouraged to innovate. You will collaborate strongly with colleagues who are committed to delivering exceptional experiences. We trust, respect and consider everyone, knowing your difference will make the difference.
**What do I need?**
- Registered Nurse eligible for registration in Australia (Operating Theatres - Scrub/Scout) **and/or **Medical Device Company clinical support experience.
- Relevant tertiary qualifications in nursing and/or health information management
- Proven experience in a major hospital with significant exposure to Operating Theatres and Implantable Prosthesis Management
- Understanding of clinical coding impacts upon Diagnosis Related Groups (DRGs)
- Understanding of hospital casemix concepts in the Private Health Insurance setting
- Understanding/experience of auditing and claims in a health insurance environment
- Private Health Insurance work experience
- Understanding of private hospital contract management practices and concepts
- Understanding of Hospital Purchaser Provider Agreement contracts and relationship to claims
- Understanding of Ancillary and Medical fund rules, provider agreements and relationship to claims
- Proven experience in data report writing and interpretation
- Computer literate, with moderate to advanced proficiency with Microsoft Excel, Word, PowerPoint and PowerBI
**What is it like to work there?**
Bupa is an international healthcare group which has been committed to a purpose of helping people live longer, healthier, happier lives and making a better world for more than 70 years.
Bupa Asia Pacific operates in Australia, New Zealand, and Hong Kong, supporting about 6.5 million customers through a broad range of health and care services including health insurance, aged care, dental, medical, optical, and hearing services.