Tariffs and Billing Rules Quality Assurance Specialist at GEMS

About the position

Introduction

The position of Tariffs and Billing Rules Quality Assurance Specialist is vacant. The Tariffs and Billing Rules Quality Assurance Specialist will report directly to theManager: Tariff and Billing Rules Quality Assurance and Alternative Reimbursement Model (ARM) and form part of the Healthcare Management Division. The position is based at GEMS Head Office in Pretoria.

The total remuneration package is R 1 136 890 per annum, based on qualifications and experience.

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

Duties & Responsibilities

The Tariffs and Billing Rules Quality Assurance Specialist will be required to provide support to the Tariffs and Billing Rules Manager through the implementation of the following Key Performance Areas (KPAs):

• Work closely with the Tariff File Coordinator, Coding Specialists and Managers, and Clinical Managers in delivering work of a high standard
• Support the Scheme Funding decisions through quality review, application, and validation of any changes to the GEMS Master Tariff and Billing Rules Files based on best practice standards.
• Work closely with the Clinical Team in ensuring that the GEMS Master Tariff and Billing Rules Files are in line with evidence-based medicine and industry dynamics.
• Ensure accurate application of the GEMS Master Tariff and billing Rules Files by Service Provider Networks (SPNs) in accordance with GEMS requirements.
• Evaluate GEMS Master Tariff and billing Rules Files quality and inefficiencies and recommend corrective action.
• Assists in monitoring and managing SPNs' SLA compliance.
• Identify, assess and mitigate risk

Desired Experience & Qualification

• Minimum of a 3-year Degree, Diploma or NQF Level 6 Diploma/Degree in Medical/Clinical Sciences Qualification (e.g. Nursing, Occupational therapist, Physiotherapist or Pharmaceutical qualification.)
• Minimum 3-5 years of extensive coding quality assurance experience
• Minimum 5 years of tariff coding and billing rules experience
• At least 5 years of managed care and/or medical schemes administration
• At least 5 years experience in claims assessing, processing and quality checking.
• 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
• Intermediate to Advanced MS Office skills
• Sound planning/ project management skills
• Have a diligent work ethic with attention to detail
• Must be in a position of a driver's license with own vehicle and be willing to travel on short notice

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.