Manager: Tariffs and Billing Rules – Medical Scheme – Pretoria

The Manager: Tariffs and Billing Rules reports directly to the Senior Manager: Healthcare Management and forms part of the Healthcare Management Division. The position is based in Pretoria.

Key Performance Areas (KPAs):
? Manage the entire organisation’s tariff file;
? Manage the entire organisation’s Billing Rules Manual;
? Manage and evaluates service levels of the scheme’s managed care service providers in relation to tariffs and billing rules on a monthly and quarterly basis;
? Produces a report on all engagement between the Division and providers (i.e. healthcare; and non-healthcare service providers) with regards to tariffs management and billing rules;
? Manages and monitors tariffs and billing rules on monthly and quarterly basis;
? Manage and support the implementation of ARMs;
? Supports in rolling out hospital network in accordance with approved programme and in line with the approved tariff rate by BoT;
? Ensures timeous submission of all tariff, billing rules and ARM reports from SPNs;
? Manages the implementation of the full and final settlement agreements with regards to matters relating to tariff, billing rules and ARMs;
? Ensures that the engagements with hospital groups, pathologists and other healthcare providers on tariffs, tariff increases and/or negotiated rates conducted in accordance with the approved Provider Relationship Strategy;
? Supports the implementation of provider relationship strategy;
? Manages adherence to circulars and regulatory changes;
? Manage the review of the Tariff Management and Billing Rules SOP’s;
? Conducts industry research to improve Scheme efficiency with regard to tariff, coding and billing rules management;
? Manage all tariff related enquiries and prioritize resolution of queries escalated to the Principal Officer, Executive Management and Senior Manager of HM division; and
? Performs a secretarial function for Healthcare Management where required; e.g., in stakeholders’ meetings;

Qualification requirements are:
? Three (3) year National Diploma in Clinical Sciences (medical/ nursing/ physiotherapy/psychology etc.);
? A degree will be added as advantage;
? At least 6-8years functional experience in the healthcare funding/ or medical Scheme industry;
? Be a subject matter expert or specialist in tariff and billing rules field;
? Knowledge Management Skills;
? Experience in case management will be advantageous;
? Sound planning/ project management skills;
? Must be in a position of a drivers licence with own vehicle and be willing to travel on short notice;
? Be organised and have good time management skills;
? Be analytical and have ability to manage priorities;
? Professional behaviour, and Have ability to work well as part of a team; Be responsible and reliable;
? Self-motivated and pro-active; and Have strong negotiation skills;
? Have resilient pressure management skills;
? Customer focus;
? Presentation Skills;
? Managerial/Couching/ Mentoring Skills;
? Have a strong orientation to the medical field of work;
? Must have had experience in the development and presentation of management reports;
? Be computer literate at advanced level; and
? Excellent verbal and written communication, and interpersonal skills;