We are looking for a Medical Coding Specialist.
The Medical Coding Specialist is responsible for the annual and quarterly maintenance of the correct coding initiatives for Doctors and Hospitals. The correct coding is based on ICD10, CPT, CCSA and NRPL tariff guides as well as the numerous new and amended coding structures published by the relevant associations since 2010. The specialist is also responsible for the design, construction, sign-off and implementation of benefit and exclusion rules and baskets of care relating to Medical Scheme benefit designs for Doctor, Radiology, Pathology and Hospital benefits.
The combination of the electronic rule construction for industry correct coding and scheme benefit rules assists the Administrators and Medical Schemes in reducing the manual over-head of assessing and pre-assessing staff as all the claims can be adjudicated 100% accurately and consistently against these rules. There will be a small percentage of these claims which will be subject to clinical case management and review which requires human intervention. The specialist will review the claims processed against the rules for accuracy and to identify trends for training and enhancements to the Universal Group’s coding and pricing products.
The specialist will be responsible for the design, specification, project management, test cases, documentation and implementation of any new enhancements relating to medical coding and pricing products.
The specialist is required to support the various internal departments throughout the company such as:
- Call centre – Training and active coaching
- Client Management Team – design of tariff code rules for benefit designs
- Provider Sales Team – design of new products, training provider communication, provider billing and coding analysis
- System Quality Assurance – support on test cases for coding and tariff detail
The work undertaken by the Medical Coding Specialist is highly complex and requires an in- depth understanding of industry rules related to correct coding and pricing. The position will demand a high attention to detail with the ability to work from concept, big picture to the lowest level of detail. The specialist will also be required to fulfil traditional roles of Business Analysis, Software Quality Testing, Training and Coaching.
The position increasingly needs you to have knowledge of a variety of coding and industry changes and as a result it is critical that you remain current with all changes as well as researching best practises around the world.
Duties and Responsibilities
- Analysing CPT, CCSA, SAMA, NHRPL, custom tariff guides for changes and rule applications for correct coding.
- Analysing scheme benefit designs to implement coding rules for compliance.
- Researching, designing and writing specifications for the establishment of the new provider products required relating to pricing and coding.
- Compile and review the rule combinations for various claims processing companies (MK, Universal Administrator
- Analysis and design of the Provider and Scheme products relating to pricing and coding.
- Testing of the changes and error resolution.
- Strategic and operational monitoring on the application of pricing and coding.
- Training and Coaching – external customers (schemes and providers) as well as the internal call centre and operational teams.
Required profile for job ad : Medical Coding Specialist - Windhoek
Minimum Qualifications and Experience Required
- Matric/ Grade 12
- At least 10 years of experience in healthcare claims processing.
- Minimum of 3 years coding experience ( NRPL all publications and Private publications)
- Business Analysis and Project Management experience and advantage
- Training/Coaching experience
