Ashley Letswalo

Investigate suspected Fraud, Waste and Abuse (FWA) cases identified by Fraud Forums, Forensics Units, and internal stakeholders, ensuring timely resolution and escalation. Analyse healthcare claims data, utilisation patterns, ICD-10, RPL, CCSA, level of care, and billing trends to identify fraud indicators, over-servicing, and irregularities. Conduct provider and member profiling to identify trends, anomalies, high-risk behaviours, and potential financial exposure.

Clinical Auditing Case Manager at Afrocentric Health (2025-07 – Present)

• Investigate suspected Fraud, Waste and Abuse (FWA) cases identified by Fraud Forums, Forensics Units, and internal stakeholders, ensuring timely resolution and escalation.
• Analyse healthcare claims data, utilisation patterns, ICD-10, RPL, CCSA, level of care, and billing trends to identify fraud indicators, over-servicing, and irregularities.
• Conduct provider and member profiling to identify trends, anomalies, high-risk behaviours, and potential financial exposure.
• Review clinical, claims, and forensic information to assess risk, validate findings, and support investigation outcomes.
• Prepare and maintain fraud investigation reports, case summaries, risk assessments, and supporting documentation.
• Collaborate with medical advisors, forensic investigators, clinical teams, claims departments, and service providers to assess and resolve complex cases.
• Liaise with healthcare providers, members, and external stakeholders regarding investigations, corrective actions, and compliance requirements.
• Monitor fraud trends and emerging risks, supporting the implementation of controls and interventions to reduce FWA exposure.
• Maintain and update the Fraud Risk Register, ensuring accurate reporting of risks, mitigation actions, and outcomes.
• Contribute to fraud management, clinical governance, process improvement initiatives, and the development and review of SOPs.
• Perform quality assurance reviews of information received from internal and external stakeholders to ensure accuracy, completeness, and compliance.
• Participate in fraud forums, case review meetings, and stakeholder engagements, presenting findings and recommendations.
• Support continuous improvement, cost containment, risk management, and customer-centric service delivery within the healthcare funding environment.

Officer: Bill Review at Road Accident Fund (RAF) (2024-01 – 2025-06)

Contract position

• Assessed healthcare claims and invoices from hospitals, doctors, and allied healthcare professionals to determine validity, appropriateness, and eligibility for payment.
• Conducted bill reviews against approved tariffs, contracts, and official fee schedules, applying ICD-10, CPT, UPFS, RPL, and CCSA coding systems to validate claims and treatment costs.
• Evaluated the appropriateness of treatment, level of care, length of stay, and quality of care, identifying and rejecting non-compliant, excessive, or unreasonable claims.
• Performed medical and injury assessments, compiled injury assessment reports, and evaluated claimants' eligibility for general damages and related compensation benefits.
• Pre-authorised procedures, admissions, treatment plans, and healthcare services in accordance with RAF clinical guidelines, treatment protocols, formularies, and tariff schedules.
• Authorised medical claim payments within delegated authority limits while ensuring clinical appropriateness, regulatory compliance, and cost effectiveness.
• Reviewed claimant hospitalisation requirements, substantiating treatment rendered, medical necessity, level of care, and duration of admission.
• Coordinated claimant care plans, monitored treatment progress and recovery outcomes, and recommended interventions, alternative treatment options, or adjustments where necessary.
• Managed discharge planning and continuity of care to ensure effective rehabilitation and ongoing treatment following hospital discharge.
• Engaged healthcare providers and service suppliers to obtain supporting clinical and administrative documentation and resolve claim-related queries.
• Escalated complex or clinically uncertain cases to Medical Advisors and multidisciplinary review panels for assessment, adjudication, and decision support.
• Prepared detailed bill review, case management, and medical assessment reports to support accurate claim adjudication and settlement decisions.
• Managed and expedited recommendations relating to Undertaking Certificates and Interim Undertaking Certificates.
• Participated in the implementation and continuous improvement of medical claims assessment processes, clinical governance initiatives, and operational procedures.
• Collaborated with internal stakeholders, healthcare providers, and medical advisors to facilitate timely claim processing, cost containment, and quality healthcare outcomes.

Intermediate Hospital Clinical Coder at Netcare Pholoso Hospital & Netcare Unitas Hospital (2022-08 – 2023-12)

• Applied intermediate ICD-10 and clinical coding principles to hospital cases, supporting accurate classification and coding of clinical conditions and procedures.
• Reviewed clinical documentation and coding information to support accurate billing, claims submission and reimbursement processes.
• Audited complicated and high-cost coding cases and identified coding or documentation issues requiring correction or further review.
• Supported resolution of rejected cases by analysing medical scheme feedback and coordinating corrective actions.
• Engaged doctors and other healthcare professionals regarding clinical documentation and information required to support accurate coding and claims.
• Supported financial risk management by ensuring coding and claims information was aligned with applicable clinical and billing requirements.
• Participated in educational workshops and training to strengthen clinical coding, technical knowledge and professional capability.

Acting Senior Case Manager at Netcare Pholoso Hospital (2021-11 – 2022-07)

• Provided case management support for complex hospital patients, coordinating clinical information and care requirements across multidisciplinary teams.
• Managed financial and clinical risk by communicating relevant patient and treatment information to medical schemes and other funding stakeholders.
• Coordinated with doctors and healthcare professionals to create and evaluate individualised care plans and support appropriate treatment and rehabilitation.
• Monitored complex and high-cost cases and supported resolution of clinical, authorisation and billing-related queries.
• Applied ICD-10 and CPT coding principles and hospital guidelines to support accurate clinical and financial case management.
• Audited complicated and high-cost cases and supported the resolution of rejected claims based on medical scheme feedback.
• Distributed tasks among team members to support daily operational targets and continuity of service.
• Participated in professional education, workshops and training to maintain and improve technical and clinical knowledge.

Case Manager at Netcare Pholoso Hospital (2021-04 – 2021-11)

• Managed clinical case information and supported coordination of patient care within the hospital environment.
• Communicated with medical schemes and relevant stakeholders regarding patient clinical information, treatment requirements and funding-related matters.
• Supported doctors and multidisciplinary healthcare professionals with care planning, treatment coordination and rehabilitation requirements.
• Reviewed complex cases and supported appropriate coding, documentation and claims processes.
• Assisted with resolving rejected claims and clinical queries through review of scheme feedback and engagement with relevant stakeholders.
• Maintained accurate clinical and administrative information to support continuity of care and financial risk management.

Phlebotomist at National Health Laboratory Service (NHLS) (2020-12 – 2021-03)

Fixed-term Contract

• Performed phlebotomy and supported COVID-19 testing services at Lebombo Border Gate.
• Collected and handled specimens in accordance with applicable clinical and infection prevention requirements.
• Supported accurate documentation and processing of testing information in a high-volume border health environment.
• Worked collaboratively with healthcare and laboratory teams to support efficient testing operations and patient flow.

Professional Nurse at UGM Wellness Clinic (2020-10 – 2020-11)

Contract

• Provided professional nursing care within a wellness clinic and COVID-19 quarantine environment.
• Supported patient assessment, monitoring, health education and appropriate referral or escalation of clinical concerns.
• Worked within infection prevention and control requirements in a COVID-19 response setting.
• Maintained accurate clinical records and communicated relevant patient information to the multidisciplinary healthcare team.

Professional Nurse at Life Health Care Via Seanda Agency (2020-06 – 2020-09)

Contract

• Provided professional nursing care within a COVID-19 isolation facility.
• Conducted patient monitoring, clinical observations, treatment support and escalation of clinical concerns.
• Maintained infection prevention and control standards and supported safe patient care within the isolation environment.
• Collaborated with the multidisciplinary healthcare team to support continuity and quality of care.

Community Service Registered Nurse at FH Odendaal Hospital (2019-02 – 2020-01)

Community Service

• Delivered professional nursing care across maternity, paediatrics, neonatal, operating theatre, CSSD, casualty and emergency, medical and surgical wards.
• Conducted patient assessments, implemented nursing care plans and monitored patient progress in line with professional nursing standards.
• Collaborated with medical practitioners and multidisciplinary teams to coordinate safe and effective patient care.
• Supported patient education, discharge planning, infection prevention and control, and continuity of care.
• Worked across diverse clinical environments, adapting to varying acuity, patient needs and operational requirements.

Postgraduate Diploma in Public Health – University of South Africa (UNISA) (2025)

Advanced Certification in ICD-10 – Netcare and Wits Consortium (2023 – 2023)

Skills Programme in Coaching and Mentoring – Advanced Assessments and Training (2023 – 2023)

Multiple Certifications in Clinical Coding – Africode (2021 – 2023)

Diploma in Nursing (General, Psychiatric and Community) and Midwifery – Limpopo College of Nursing (2015 – 2018)

Certification in Integrated Management of Childhood Illness – Limpopo College of Nursing (2017 – 2018)

National Senior Certificate in Grade 12 – Ramabu High School (2011 – 2011)