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 company 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 center – 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 practices around the world.

Key Responsibilities:

• Analyzing CPT, CCSA, SAMA, NHRPL, custom tariff guides for changes and rule applications for correct coding.
• Analyzing 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.
• 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 center and operational teams.

Experience and Qualifications Required:

• 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

Key Competencies and Skills

• Analysis with excellent attention to detail
• Planning and organization skills
• Quality orientation as well as setting of quality work standards for others.
• Conceptual to implementation skills
• Self Managed and Self Motivated with the ability to motivate others.
• Ability to form and lead a cross functional team focusing on delivery.
• Effective problem-solving skills; to be resourceful and do research and to resolve problems.
• Excellent communication (verbal and written) and people skills needed for teamwork and identifying end user requirements.
• ICD10, NHRPL, CPT, CCSA coding skills
• Ability to identify and implement continuous improvements throughout the organisation.
• Ability to identify and improve the rule stacking systems to ensure it is compliant to legislation, regulations, and industry changes and remains innovative to implement scheme benefit designs.
• Ability to multi-task and stay organized in a dynamic work environment.
• Ability to work productively in a team as well as lead a team.

Language Requirements

• Writing and speaking fluent and correct English
• Speaking and writing in one other official language would be an advantage.
• Extensive understanding of medical and healthcare terminology.

Computer Literacy

• Proficiency with the following programmes is required:
• MS Word
• MS Excel
• MS Outlook / email
• MS Explorer / Internet
• PDF editor

 Closing Date: 19 June 2026