Clinical Quality Assurance Officer

Location: Centurion, Gauteng

Position Purpose:

To ensure that clinical services meet established quality standards, regulatory requirements, and best practice clinical guidelines. This role drives measurable improvements in member care, clinical outcomes, utilization management, and adherence to statutory frameworks.

Experience:

• 3-5 years' experience in clinical quality assurance, auditing, utilisation management, medical claims review, or related healthcare quality role within a medical aid / medical scheme / healthcare funder environment.
• Solid understanding of South African healthcare regulatory frameworks (CMS, PMBs, risk adjustment).

• Matric
• Bachelor's degree in nursing or related healthcare qualification.
• Post-graduate qualification in Quality Management will be advantageous.

• Strong clinical auditing and analytical skills.
• Knowledge of clinical coding systems (ICD-10, CPT / NAPPI) and utilisation review.
• Excellent report writing, presentation, and stakeholder engagement skills.
• High attention to detail and ability to identify patterns in clinical data.
• Ability to work independently and as part of a multidisciplinary team.
• Proficiency in MS Office with advanced excel and clinical information systems.
• Timely completion of clinical audits with actionable recommendations.
• Identify training gaps and reduce clinical risk exposure through findings.
• Improvement in key quality measures (e.g. appropriateness of care, readmissions, PMB compliance).
• Conduct consistent quality assessments by the required deadlines and provide impactful feedback on identified quality issues, concerns and successes that lead to measurable improvements
• Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary

Skills and Abilities

• Business writing skills
• Computer technology skills
• Problem solving
• Attention to accuracy and detail
• Numerical ability
• Relevant systems knowledge and application

Knowledge

• Understanding of call centre technology
• Knowledge of scheme rules and contractual negotiations
• Knowledge and application of relevant legislation
• Knowledge and application of clinical processes and procedures

Note: Company reserves the right to close the advert before specified closing date.