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GOVERNMENT EMPLOYEES MEDICAL SCHEME (GEMS)
 


​MANAGER: TARIFF AND BILLING RULES (T&BR) QUALITY ASSURANCE AND ALTERNATIVE REIMBURSEMENT MODEL (ARM)
  • Pretoria
  • Permanent
  • Full Time
 
Manager: Tariff and Billing Rules (T&BR) Quality Assurance and Alternative Reimbursement Model (ARM)Government Employees Medical Scheme - GEMS
Introduction
The position of Manager: Tariff and Billing Rules (T&BR) Quality Assurance and Alternative Reimbursement Model (ARM),  is vacant. The Manager: Tariff and Billing Rules (T&BR) Quality Assurance and Alternative Reimbursement Model (ARM), will report directly to the Senior Manager: Tariffs and Billing Rules and forms part of the Healthcare Management Division. The position is based at GEMS Head Office in Pretoria.
The total remuneration package is R 1 386 956 per annum, based on qualifications and experience.
 
Duties & Responsibilities
The Manager: T&BR Quality Assurance and ARM will be required to provide support to the Senior Manager: Tariffs and Billing Rules through the identification of event request received from various departments and the implementation of the following Key Performance Areas (KPAs):
  • Support the SM: T&BR in ensuring that the GEMS T&BR masters file quality is of high standard and aligns to best practice standards to achieve the strategic objectives of the HM division and the Scheme.
  • Support the Scheme funding decisions through the establishment of ARMs, quality review, application, and validation of any changes to the GEMS Master Tariff and Billing Rules Files based on best practice standards.
  • Assist all internal and external stakeholders by ensuring that the ARMs and the GEMS T&BR Master Files are in line with evidence-based medicine and industry dynamics.
  • Ensure accurate application of the GEMS T&BR Master Files by Service Provider Networks (SPNs) in accordance with GEMS quality requirements.
  • Evaluate GEMS T&BR Master Files quality and inefficiencies and recommend corrective action.
  • Assists in monitoring and managing SPNs’ SLA compliance.
  • Identify, assess and mitigate risk
 
Desired Experience & Qualification
  • A relevant Degree or Diploma in clinical science/nursing
  • Minimum 5 years of extensive experience in clinical coding and quality assurance
  • Minimum 5 years of tariff coding and billing rules experience
  • Extensive practical experience in Alternative Reimbursement Model and Value-Based Care
  • Extensive experience in managed care and/or medical schemes administration
  • At least 5 years’ experience of data handling
  • Manager/Team Leader experience in tariff coding and claims management environment
  • Experience in Stakeholder engagement
  • Excellent quality check and quality assurance skills
  • Attention to detail and have a diligent work ethic
  • A good understanding of ICD10, CPT 4, NAPPI and tariff coding
  • A good understanding of the Medical Schemes Act
  • Strong analytical and administrative skills
  • Strong verbal and written communication and interpersonal skills
  • Good organisational ability with time management skills and ability to meet tight deadlines
  • Critical thinking skills and the ability to work independently under pressure and as part of team.
  • High-level initiative as a self-starter, reliable and proactive
  • Have resilient pressure management skills.
  • Report writing and presentation skills
  • Sound planning/ project management skills
  • Must be in a position of a driver's license with own vehicle and be willing to travel on short notice
  • Research and Data analysis skills
 
Interested?
GEMS employs people with the highest level of integrity – submission to the appropriate pre-employment assessment is obligatory to be considered for the position.
Kindly note that the information provided on application of the position may be shared with a third party for vetting purposes and will be stored by GEMS for a period of 5 years.
Kindly note that information is required for Employment Equity Purposes and information gathered is strictly used according to the intended purpose of collection, unless there is a legal need or permission is granted from the applicant themselves to make use of it for other purpose.
Should you wish to have your information removed from the GEMS database, kindly send a request in writing to jobs@gems.gov.za.
GEMS adopts a hybrid work model.
GEMS is guided by the principles of employment equity. Preference will be given to groups who are underrepresented in accordance with GEMS employment equity plan.
Successful candidates will be required to seek approval to conduct other work outside of GEMS.

GEMS Employees are required to conduct themselves in a manner that reflects the organisation's paramount values: Excellence, Member Value, Integrity, Innovation, and Collaboration.
 
PLEASE APPLY HERE












​TARIFFS AND BILLING RULES QUALITY ASSURANCE SPECIALIST
  • Pretoria
  • Permanent
  • Full Time
 
Tariffs and Billing Rules Quality Assurance SpecialistGovernment Employees Medical Scheme - GEMS
Introduction
The position of Tariffs and Billing Rules Quality Assurance Specialist is vacant. The Tariffs and Billing Rules Quality Assurance Specialist will report directly to the Manager: Tariff and Billing Rules Quality Assurance and Alternative Reimbursement Model (ARM) and form part of the Healthcare Management Division. The position is based at GEMS Head Office in Pretoria.
The total remuneration package is R 1 136 890 per annum, based on qualifications and experience.
 
Duties & Responsibilities
The Tariffs and Billing Rules Quality Assurance Specialist will be required to provide support to the Tariffs and Billing Rules Manager through the implementation of the following Key Performance Areas (KPAs):
  • Work closely with the Tariff File Coordinator, Coding Specialists and Managers, and Clinical Managers in delivering work of a high standard
  • Support the Scheme Funding decisions through quality review, application, and validation of any changes to the GEMS Master Tariff and Billing Rules Files based on best practice standards.
  • Work closely with the Clinical Team in ensuring that the GEMS Master Tariff and Billing Rules Files are in line with evidence-based medicine and industry dynamics.
  • Ensure accurate application of the GEMS Master Tariff and billing Rules Files by Service Provider Networks (SPNs) in accordance with GEMS requirements.
  • Evaluate GEMS Master Tariff and billing Rules Files quality and inefficiencies and recommend corrective action.
  • Assists in monitoring and managing SPNs’ SLA compliance.
  • Identify, assess and mitigate risk
 
Desired Experience & Qualification
  • Minimum of a 3-year Degree, Diploma or NQF Level 6 Diploma/Degree in Medical/Clinical Sciences Qualification (e.g. Nursing, Occupational therapist, Physiotherapist or Pharmaceutical qualification.)
  • Minimum 3-5 years of extensive coding quality assurance experience
  • Minimum 5 years of tariff coding and billing rules experience
  • At least 5 years of managed care and/or medical schemes administration
  • At least 5 years experience in claims assessing, processing and quality checking.
  • A good understanding of ICD10, CPT 4, NAPPI and tariff coding
  • A good understanding of the Medical Schemes Act
  • Strong analytical and administrative skills
  • Strong verbal and written communication and interpersonal skills
  • Intermediate to Advanced MS Office skills
  • Sound planning/ project management skills
  • Have a diligent work ethic with attention to detail
  • Must be in a position of a driver's license with own vehicle and be willing to travel on short notice
 
Interested?
GEMS employs people with the highest level of integrity – submission to the appropriate pre-employment assessment is obligatory to be considered for the position.
Kindly note that the information provided on application of the position may be shared with a third party for vetting purposes and will be stored by GEMS for a period of 5 years.
Kindly note that information is required for Employment Equity Purposes and information gathered is strictly used according to the intended purpose of collection, unless there is a legal need or permission is granted from the applicant themselves to make use of it for other purpose.
Should you wish to have your information removed from the GEMS database, kindly send a request in writing to jobs@gems.gov.za.
GEMS adopts a hybrid work model.
GEMS is guided by the principles of employment equity. Preference will be given to groups who are underrepresented in accordance with GEMS employment equity plan.
Successful candidates will be required to seek approval to conduct other work outside of GEMS.
GEMS Employees are required to conduct themselves in a manner that reflects the organisation's paramount values: Excellence, Member Value, Integrity, Innovation, and Collaboration.
 
PLEASE APPLY HERE