Clinical Audits Team Lead

General information

Description & Requirements

The opportunity: 

We are seeking an experienced and results-driven Clinical Audits Team Lead to oversee initiatives that reduce non-compliant hospital benefit outlay through strategic claims leakage prevention. In this key leadership role, you will manage the end to end onsite and desktop auditing process, assist with compliance monitoring and optimise system controls to ensure effective cost management and contract integrity.
We're looking for a strong, proactive leader who can create a positive culture and drive measurable results.

Regular interstate travel may be required.

This is a permanent role, that can be based in Melbourne, Brisbane, or Sydney. 

We offer hybrid work arrangements, so you’ll have the flexibility to work from home when you aren’t visiting sites or working from the office in the Melbourne/Brisbane/Sydney CBD. 
  

To be successful in this role, you’ll need to have:

• Tertiary qualifications in relevant areas (nursing, health information management, clinical coding, management etc) or equivalent experience (desirable).
• Prior experience in a clinical setting, preferably with a background in Special Care Nursery (SCN) or Intensive Care Unit (ICU) (desirable).
• Audit experience in health insurance or hospital environment (desirable).
• Proven experience in successfully leading small teams to achieve strong KPI’s.
• An understanding of Hospital Casemix Protocol (HCP) data submission process.
• An understanding of Hospital Purchaser Provider Agreement contracts, Clinical Coding, Medicare Benefit Schedule, and relationship of these to hospital claims 
• Experience in a major private or public hospital with significant exposure to operating theatre (various specialities) and/or ICU areas.
• The ability to recognise trends, insights, and patterns using complex data sets and reports.

How will I help?

You will add value by:

• Leading and mentoring a team of clinical coders and health Information managers to consistently deliver high quality, impactful audit results in line with the Clinical Audit operational goals.
• Under direction of the Manager, Hospital & Medical Integrity, leading the development of a plan or programme of both onsite and desktop Clinical and DRG audits. 
• Assisting in the preparation and completion of onsite provider audits.
• Managing and monitoring end to end processes including follow up and financial management of incorrect billing as per the agreed annual work program. 
• Providing analysis and/or reporting of non-compliant billing trends and escalate to stakeholders as required.
• Providing clinical advice on statistical reports produced by Data Scientists and Claims Analysts to determine if further investigation and action is warranted. 
• Initiating and developing relevant data reports to identify areas of actual and potential claims leakage.

Why work at Bupa?

A career at Bupa is more than just a job. It’s an opportunity to make a real difference in the lives of our customers and communities. Our purpose, helping people live longer, healthier, happier lives and making a better world, is what inspires us. It’s a promise to our customers to change lives, and our world, for the better. Our people are at the heart of this. It’s their passion, ideas and commitment that will shape a brighter future for both Bupa and our customers.

We’ve evolved from being simply a health insurer to what we call a ‘health and care’ company. This involves providing more wide-ranging services to benefit people’s health and wellbeing, wherever they are in life. 

If you’ve got the belief, the energy, and the talent, come and join us.

To learn more about working at Bupa please visit our website: www.bupa.com.au/careers

Bupa is an equal opportunity employer. We are committed to ensuring equality in recruitment, development, retention, and promotion of staff and that no-one is disadvantaged based on their gender, cultural background, disability, sexual orientation or identity, or Aboriginal and Torres Strait Islander heritage. 

We encourage people from all backgrounds to apply. If you require any adjustments to participate in our recruitment process, please let us know at the time of your application.