A Managed Healthcare Company based in Sandton has a vacancy for a Clinical Coding Specialist.

The Clinical Coding Specialist is responsible for the management of all tariff files, including, year-end tariff changes, deletion and inclusion of new tariffs, tariff motivation process and providing clinical appropriateness and validation of all codes. The Clinical Coding Specialist will conduct systemic continuous review of tariffs and ensure the Scheme’s funding decisions are based on best practice. This activity aims to ensure that these elements are sound and in compliance with the Medical Schemes Act and Regulations, as well as the Scheme Rules at all times.

These responsibilities will include ensuring that the Managed Care organisation is in line with evidence-based medicine and Administration pay claims according to agreed and appropriate tariffs, evaluate appropriateness and unnecessary expenditure, recommend corrective action and ensure inclusion and deletion of tariffs that support Schemes strategic objectives and mandates.

Duties and responsibilities
•Coordinate all tariff files for all disciplines.
•Reviewing and accurately interpreting tariff applications and rulings.
•Evaluate tariffs for clinical appropriateness.
•Make recommendations on tariffs based on funding rules.
•Provide clinical studies and Health Economic Evaluation to support tariff responses.
•To develop and maintain knowledge of how tariffs are used in programming and how these are licensed.
•Ensure that tariff files are delivered in the right format or has the right price.
•Maintain a tariff file change control and audit process for all amendments.
•Ensure timeous validation and implementation of tariffs as required.
•Contribute to the targeted research on clinical tariff guidelines and funding policies.
•To develop and maintain a general technical understanding of tariff files and how these are downloaded.
•To carry out troubleshooting when the Scheme is having difficulties, working closely with technical support to sort out the problems with the processes and the actual files.
•Monitor medical literature and use evidence-based principles to generate enhancements in tariff funding protocols.
•Provide final testing to ensure accuracy of tariff application.
•Maintain a pricing structure file for all products and disciplines.
•Executing changes in the pricing structure when required.
•Advising management on potential exposures and course of action based upon rulemaking procedures related to tariffs.
Experience and qualifications required
•The candidate must be a registered nurse with the South African Nursing Council
•Minimum of 5 years’ experience in the managed care environment
•In-depth knowledge of coding interpretation
•Knowledge on tariffs
•A good understanding of the Medical Schemes Act
•Analytical and administrative skills
•Strong verbal and written communication skills
•The ability to conduct research using a variety of academic and market-related resources
•Continuous hands on clinical experience - work once a quarter in a hospital environment
Computer literacy

•Proficiency in the following programs is required:
?MS Word
?MS Excel (must know Pivot tables, Vlookup and formulas)
?MS Outlook/email
?MS Explorer/Internet