Manager: Tariff and Billing Rules (T&BR) Quality Assurance and Alternative Reimbursement Model (ARM) at GEMS

About the position

Introduction

The position of Manager: Tariff and Billing Rules (T&BR) Quality Assurance and Alternative Reimbursement Model (ARM), isvacant. 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.

The closing date for applications will be Tuesday , 07 October 2025.

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 [Email Address Removed] .
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.