Case Management Quality Assessor

SUMMARY:
The incumbent will be responsible in collaboration with hospital case management teams, for liaising between the patients, medical doctors and medical schemes in Order to provide clinical coding that is updated in accordance with the patient response to treatment in order to receive reimbursement from funders.

POSITION INFO:

KEY PERFORMANCE AREAS

• Work with billing departments to achieve clinical coding excellence on all patient files. Application of clinical and coding knowledge to effectively assign and sequence all ICD 10 and CPT codes for services rendered for each patient event.
• Read and analyse records from all available digital and other resources for accurate and appropriate coding that reflects the relevant medical history and care the patient received as well as the response to treatment.
• Comply with all legal requirements regarding clinical coding procedures and practices. Actions that are guided by the South African Code of Ethics for Clinical Coders and South African coding standards.
• Review of patient records for missing information.
• Review of PMB queries and recommendations for action.
• Communicate with funders about clinical coding errors and disputes.
• Identify discrepancies, potential quality of care and billing issues.
• Assist with ad hoc case management required at hospital level.
• Provide support to the hospital billing department.
• Assist with the training of staff regarding ICD-10 and CPT coding.
• External Customer Support.
• Contact physicians and other health care professionals with questions about treatments or diagnostic tests given to patients regarding coding procedures. Serves as coding consultant to care providers.

MINIMUM REQUIREMENTS

• Registered Nursing Diploma with current SANC Registration.
• Advanced Certificate in ICD-10 Coding (Essential).
• Advanced Certificate in Complete CPT preferred.
• Minimum of 3 years’ experience within Clinical Coding in a private hospital or managed care environment.