Billing Operations Centre (BOC) Clinical Coder - Billings Operation Centre Cape

Location: Billings Operation Centre Cape

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.

Duties & Responsibilities

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.

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 analytics team to iteratively improve on coding trends and rejection management
• Serves as a subject matter expert to case managers and internal and external stakeholders
• Mentor and coach staff on coding related matters
• Provide coding support to the hospital billing department
• Assist with the training of staff on relevant diagnostic and procedural coding schemas

External Customer Support

• Contact physicians and other health care professionals with questions about treatments or diagnostic tests given to patients regarding to coding procedures.
• Serves as coding consultant to care providers

TRANSFORMATION OF OUR SOCIETY

Build and maintain stakeholder relationships

• Develop collaborative relationships to help accomplish work goal.
• Maintain customer intimacy through building relationships with billings teams, doctors, nursing staff and other relevant internal and external stakeholders.
• Build strategic inter-departmental relationships to help achieve business goals at Exco and departmental level within the hospitals and BOCs.
• Foster an effective working relationship with staff and internal and external stakeholders.

Personal and professional development

• Develop collaborative relationships to help accomplish work goals
• Support of national initiatives and assist in responding to the changing business needs and development within Netcare
• Active involvement in own professional development to maintain a satisfactory level of skill and knowledge

SKILLS PROFILE

EDUCATION

Essential

• Diploma or degree in Nursing or equivalent NQF level 6 qualification within healthcare sciences
• Certificate in Advanced ICD-10 or completion of Netcare Advanced ICD-10 training
• SANC registration as a Registered Nurse or equivalent professional body

Preferred

• Completed a CCSA (Complete CPT® for South Africa) coding course or completion of Netcare Discipline specific CCSA coding training

WORK EXPERIENCE

Essential

• SANC registration as a Registered Nurse or equivalent professional body

KNOWLEDGE

Essential

• CCSA coding and an understanding of coding standards
• ICD-10 coding and an understanding of coding standards
• Multi-disciplinary clinical experience and knowledge of medical terminology
• Excellent communication skills
• Attention to detail
• Ability to work extended hours
• Anatomy and physiology
• Intermediate computer proficiency

NON-MANAGERIAL/ SPECIALIST SKILLS

Taking Action

Capable of recognising the need for action, considering possible risks and taking responsibility for results.

Decision Making

Capable of making decisions timeously and taking responsibility for the consequences.

Managing Self

Capacity to plan, organise and control own work environment by setting appropriate priorities and achieving set objectives within a given time frame.

Customer Focus and Service Delivery

The capacity to identify and respond to the needs of *internal and external customers.

• Internal and external customers include patients, doctors, colleagues, suppliers, visitors, vendors and any other person that requires a relationship

Continuous Improvement

The capacity to improve systems and processes to facilitate continuous improvement.

Personal Work Ethic

Capacity to instil an ethic of ownership, quality and consistency in self and others.

Building Relationships

Capacity to establish constructive and effective relationships.

Communication

The capacity to clearly present information, either written or verbal.

Teamwork

Capacity to cooperate with others to work towards a common goal.

PHYSICAL REQUIREMENTS

In the event of any physical or psychological limitation that may impair the employees ability to perform the required job function, the employee must consult the employer for reasonable accommodation.

VALUES AND BEHAVIOURS

Netcare Values

At Netcare, our core value is care. We care about the dignity of our patients and all members of the Netcare family. We care about the participation of our people and our partners in everything we do. We care about truth in all our actions. We are compassionate about quality care and professional excellence.

• Care - The basis of our business. The professional, ethical patient care and services we offer at every level of the organisation.
• Truth - The crucial element in building relationships that work. Open communication with honesty and integrity is essential.
• Dignity - An acknowledgement of the uniqueness of individuals. A commitment to care with the qualities of respect and understanding.
• Compassion - The creative, compassionate and innovative drive to do things better than before. To develop and implement successful healthcare solutions for all.
• Participation - The willingness and desire to work in productive and creative partnerships with others and the commitment to communicate.

The Netcare Way

Netcare is committed to providing you with the best and safest care. Our basic service standard holds us accountable for the below seven behaviours:

• I always greet everyone to show my respect.
• I always wear my name badge to show my identity.
• I am always well-groomed to show my dignity.
• I always practise proper hand hygiene to show my care.
• I always engage to show my compassion.
• I always say thank you to show my appreciation.
• I always embrace diversity to strengthen inclusivity and belonging.

Join the team committed to providing the best and safest health and care.

Desired Experience & Qualification

See "Your Tasks".