Billing Operations Centre BOC Clinical Coder

Netcare; Johannesburg; On-site; ZAR 280,000 - 520,000; Full time

Job summary

Netcare invites you to contribute as a Clinical Coder, collaborating with patients, clinicians and funders to ensure accurate ICD-10 and CCSA coding for claims.

Under the direction of the Clinical Coding Specialist, you will review documentation, audit coding accuracy, and support revenue integrity across hospital events, driving process improvements and compliant coding in SA’s managed care environment.

Qualifications

• Review and audit clinical documentation to ensure ICD-10 and CCSA accuracy.
• Collaborate with patients, clinicians and funders to secure correct coding.
• Maintain awareness of coding standards and ethical guidelines.

Responsibilities

• Code all patient events accurately using ICD-10 and CCSA guidelines.
• Audit coding completeness and identify documentation deficiencies.
• Engage with clinicians to ensure consistent and correct coding practice.
• Support billing operations with accurate DRG and billable codes.
• Participate in process improvements to enhance coding quality.

Skills

Clinical coding

ICD-10 coding

CCSA coding

Stakeholder liaison

Tools

HCI system

Job description

We provide meaningful careers that connect people with purpose.

We are united by a common purpose of providing the best and safest care; and by our shared values of Care, Truth, Participation, Compassion and Dignity.

Netcare invites you to be part of our journey.

Under the direction of the Clinical Coding Specialist (CCS), a Clinical Coder (CC) will be responsible in collaboration with billings teams, for liaising between patients, treating clinicians and managed care organisations to provide accurate and complete coding on updates and claims.

The CC must review and/or audit clinical documentation and resultant coding on patient files to ensure the accuracy and completeness of ICD-10 and CCSA coding as well as the sequencing of codes within the managed healthcare environment. The incumbent must ensure that the ICD-10 and CCSA coding assigned, provides an accurate reflection of the patient condition, clinical severity and medical necessity of treatment received. The impact of coding on Alternative Reimbursement models/billing arrangements should be considered when assigning diagnostic and procedural codes.

The position requires a high degree of collaboration and liaising between patients, treating clinicians, and managed care organisations to provide clinical coding that is updated in accordance with the patient response to treatment to receive reimbursement from funders. This will include escalations to relevant management at Administrators or Funders for resolution where necessary.

This position involves participation in system enhancement and process improvement projects and supporting the work needed to meet departmental, institutional and broader healthcare industry operational and strategic objectives.The incumbent will provide support, initiate and manage innovation and best practice, in response to ever-changing practices influencing efficiencies impacting on clinical coding.

They participate in clinical coding which is the backbone of risk management strategies such as Alternate Reimbursement Models (ARMs) and/or billing arrangements and Value Based Contracts (VBC). The accuracy and completeness of coding affects the Diagnostic Related Grouper (DRG), Major Diagnostic Category (MDC), case mix and therefore have a direct correlation to the related cost allocation of cases. Coding is critical for accurate billing and reimbursement of cases.

KEY WORK OUTPUT AND ACCOUNTABILITIES

DISRUPTIVE INNOVATION

• Coding quality
• Application of clinical and coding knowledge to accurately assign and sequence all ICD-10 and CCSA codes for services rendered for each patient event
• Demonstrate expertise in clinical coding and the Diagnostic Related Grouper model and an understanding of the complex cause and effect factors within the broader managed care industry
• Clinical coding completeness of all patient events relevant to medical history, diagnosis, treatment rendered, and procedures carried out and response to treatment.
• Provide operational support for Billing Operation Clusters and hospitals with regards to the accuracy of ICD-10 and CCSA coding on claims
• Engage with doctors and allied service providers to ensure complete and accurate ICD-10 and CCSA coding on each case is achieved
• Audit patient events to assess accuracy and completeness of coding
• Analyse medical records and identifies clinical documentation deficiencies
• Utilize all available digital resources for accurate and appropriate clinical coding
• Measure and report on hospital clinical coding compliance
• Allocate clinical codes to patients' current period of care using knowledge of the coding information contained on HCI and other relevant platforms
• Continual assessment of work to ensure a continuous improvement in ICD-10 and CCSA coding and collection of quality health data
• Review and analyse clinical coding periodically during a patient event in relation to mapped clinical coding requirements
• Adherence to Netcare policy and procedure and measurement of performance within the designated key performance area

Compliance Management

• Actions that are guided by the South African Code of Ethics for Clinical Coders and South African coding standards
• Comply with all ethical and legal requirements regarding clinical coding and related practices
• Conduct on-going audits and clinical coding reviews to ensure all clinical coding and clinical documentation is complete and precise
• Clinical coding accuracy will be measured using reporting and trend analysis from the Netcare data analytics team

Rejection management

• Review clinical coding periodically during a patient event in relation to coding requirements, to decrease or eradicate coding errors, reduce short payments, claims rejections
• Communicate with funders about clinical coding errors and disputes
• Identify discrepancies, potential quality of care and billing issues
• Review of PMB and other coding related queries and recommendations for action

Internal Customer Support

• Participate actively with the Netcare data a