WW6123 - Senior Auditor - (Full-time) - GMHBA - Geelong, VIC

The purpose of this role is to ensure that GMHBA pays no more for services provided to its members than it is contractually obliged to pay, and to assist the Fund to ensure that health provider contracting achieves efficient and effective outcomes.
The initial focus of the role is hospital claims and over time will incorporate a broader focus across medical and ancillary claims as required of the business.

Responsibilities / Duties: 

The principle accountabilities are:

  • Assist the Audit Manager in establishing policies, procedures, guidelines and audit schedule to assist in reducing claims leakage and ensure a standard approach to clinical claims coding and audit is followed.
  • Ensure all audit functions are compliant with Australian Coding Standards, the policy requirements of the business and GMHBA audit custom and practice.
  • Assist in establish a database to enable interrogation of claims data to check validity and identify provider outlier claims.
  • Undertake the audit function according to an agreed audit schedule which includes priority focus areas, reviewed on a rolling twelve month basis with the Audit Manager.
  • Review and report on aggregated audit outcomes and trends to the Audit Manager and Benefits Manager and make recommendations from the analysis of claims for future contracting. Following the identification of claim issues provide education and support to relevant claims teams.
  • Participate in on-site hospital audits, reviewing clinical notes to confirm hospital billing as correct.
  • Provide subject matter expertise related to the audit function and case-mix benefit analysis to senior management and other areas of the business as required. Actively participate in and contribute to the strategies and initiatives of the business and the GMHBA Benefits Management Department.
  • Ensure compliance with Company Policies and Standards. Undertake other duties as assigned by the Audit Manager.

It is not the intention of this position description to limit the scope or accountabilities of the position but to highlight the most important aspects of the position. The accountabilities described within may be altered in accordance with the changing requirements of the role.

Specific Job Competencies


  • Able to read and understand claims data and medical records with the ability to determine where inconsistencies and/or outliers have occurred.

Operational Decision Making

  • Identifies and understands current issues, problems and opportunities.
  • Compares data from different sources to draw conclusions.
  • Develops alternative solutions and chooses the most effective course of action.
  • Takes action that is consistent with available facts, constraints and probable consequences.

Teamwork and Collaboration

  • Actively builds and fosters a friendly, harmonious and productive working atmosphere for all staff.
  • Actively shares knowledge and experience with others.
  • Leads by example.
  • Models respect, helpfulness and cooperation.
  • Builds a cohesive and collaborative team environment.

Conceptual Thinking

  • Understands situations or problems by identifying patterns or connections and addressing the key issues.
  • Sees the big picture in complex situations
  • Recognises when and how parts of an issue or situation affect individual and group performance.

Strategic Planning

  • Obtains information and identifies key issues and relationships relevant to long-range strategies or visions.
  • Develops alternatives based on logical assumptions, facts, resources, constraints and organisational values.
  • mplements a course of action to accomplish long-range strategies or visions.
  • Measures outcomes.


Essential Skills and Experiences
Communication (Verbal and Written)

  • Clearly conveys and cascades information and ideas, through a variety of media, to individuals or groups in ways that engages the audience and helps them to understand and retain the message. Is consultative and seeks to personalise communication to meet the internal/ external customers’ needs.
  • Actively seeks and analyses feedback and responds in an appropriate manner.

Business Acumen

  • Understands the PHI industry, corporate finance and reporting. Understands the relationship and implications of product, premium and claims calculations as relevant to their position.
  • Demonstrates knowledge of sound business processes and practices through the delivery of effective outcomes and value adding initiatives.
  • Demonstrates a sound understanding of contemporary Occupational Health and Safety standards, Equal Opportunity and other aspects of people management.

Educational Qualifications

  • Bachelor of Health Information Management or Diploma of Medical Record Administration or other recognised clinical coding course.

Experiential Requirements

  • Demonstrated experience and competency in nosology/clinical classification/coding using appropriate clinical classification systems (ICD-10-AM 8TH Edition and the Australian Classification of Health Interventions (ACHI).
  • Experience in coding in an acute hospital setting with diverse casemix.
  • Pro-Active analytical/Problem solving skills.
  • 5 years relevant professional experience in the Australian Health Industry.
  • Previous experience in health data management.
  • Confident oral and written communication skills.
  • Ability to communicate ideas in both technical and user-friendly language.
  • Effective time management, planning and organisational skills.
  • Proven practical experience with reporting tools and relational data concepts.
  • Relevant computer technical skills applicable to coding and casemix.
  • Intermediate/Advanced skills in Microsoft Office suite including excel and access and/or have an aptitude to learn.
  • Commitment to high quality outcomes.
  • Ability to think analytically, logically and laterally.


Highly Desirable

  • Demonstrated knowledge of private health sector funding model.
  • Demonstrated knowledge of casemix protocols and application of this knowledge in the audit function.
  • Knowledge of, Reports Manager, Visual Studios and BI tools.


Joanne Popovic
Audit Manager
Phone: 03 5202 8662
Email: joannepopovic@gmhba.com.au

For more information or to apply, please visit GMHBA’s current vacancies webpage.

Applications Close On: 
15 September 2017