Clinical Coding Specialist at Momentum Metropolitan Holdings Limited

Role Purpose    

• The Clinical Coding Specialist is accountable for defining, governing and enabling clinical coding frameworks across the organisation to ensure accurate claims adjudication, appropriate benefit design and effective healthcare risk management.
• The role translates clinical practice into structured coding logic, ensuring alignment between clinical policy, tariff application and system execution. This includes defining coding standards, validating coding outputs, advising on complex coding and funding scenarios, and embedding coding frameworks into clinical policies, provider engagement models and claims systems.
• The Clinical Coding Specialist operates as the subject matter authority on coding strategy and integrity, ensuring that coding practices are clinically appropriate, operationally executable and financially sustainable.

Requirements    

• A tertiary clinical qualification (e.g. Nursing degree or equivalent).
• Clinical Coding qualification, at the level of  Intermediate Training in Complete Current Procedural Terminology (CCSA)/ ICD-10.
• With significant demonstrated experience in clinical coding within a healthcare funder or administrator environment.

5+ years experience (with clinical qualification) OR 10+ years experience (clinical coding qualification) in:

• Clinical Coding
• Claims adjudication
• Medical care/medical scheme environment.
• Experience in International Classification of Diseases 10th Revision (ICD-10), Complete Current Procedural Terminology (CCSA), Reference Price List (NHRPL/RPL), and Clinical Societies coding frameworks.
• Tariff application and billing logic.
• Translating coding rules into system logic.
• Developing or maintaining coding rules, crosswalks and reference tables.
• Supporting clinical policy and benefit design through coding frameworks.
• Working across clinical, operational and system teams.

Duties & Responsibilities    

• Define and maintain clinical coding standards and governance frameworks across the organisation.
• Translate clinical policies into clear, enforceable coding logic within claims and authorisation systems.
• Design and implement coding rules, validation logic and crosswalks to support accurate adjudication.
• Provide authoritative guidance on: Appropriate code selection, Tariff application, Coding exclusions and risk scenarios, Relative value units (RVUs).
• Analyse claims and coding data to identify: Leakage, Misaligned coding practices, System or rule gaps, Financial risk, Coding errors and compliance risk.
• Drive continuous improvement through: Rule enhancements, Policy updates, System optimisation.
• Maintain and update coding databases and reference tables in line with industry and regulatory changes.
• Define and enforce coding governance standards across all coding activities.
• Perform validation and QA of coding outputs, including: Routine clinical coding requests, Complex and high-risk cases.
• Ensure consistency and accuracy of coding across: Clinical policy implementation, Claims adjudication, Provider-facing processes, System Rules.
• Identify patterns of: Incorrect coding, Inappropriate tariff application, System inconsistencies.
• Implement corrective actions through: Rule refinement, Policy clarification, Stakeholder guidance.
• Establish and monitor coding quality metrics, audit processes and controls.
• Embed coding frameworks into clinical policy design and updates.
• Ensure policies are: Clinically appropriate, Operationally executable, Aligned to coding standards and billing practices.
• Advise on funding implications of coding decisions, including: Code inclusion and exclusion, Risk of misuse or unintended utilisation.
• Support accurate and defensible: Authorisation decisions, Claims payment outcomes.
• Act as escalation point for: Coding-related funding disputes, Policy interpretation challenges.

Knowledge:

• Medical Schemes Act(131 of 1998).
• Prescribed Minimum Benefits.
• ICD-10 Master Industry Table.
• ICD-11
• International Classification of Health Interventions (ICHI)Complete Current Procedural Terminology (CCSA).

Client Services:

• Serve as the subject matter expert for clinical coding across the business.
• Provide authoritative guidance to:o    Provider teams on coding expectations and tariff interpretation.o    Clinical teams on coding implications of policy decisions.o    Informatics teams on coding structures and reporting logic.
• Systems teams on: Clinical input and review (Age, gender, LOS, LOC, etc) of various (clinical) masterfiles including but not limited to ICD-10, CCSA, etc.  Validating clinical crosswalks, billing rules, etc. Reviewing, updating and adding new underwriting exclusion clinical content. 
• Support resolution of complex coding queries and disputes.
• Ensure clear and consistent communication of coding updates across stakeholders.

Competencies    

• Business Acumen.
• Collaboration.
• Client / Stakeholder Commitment.
• Impact and Influence.
• Drive for Results.
• Self Awareness and Insight.

Closing Date    

• 2026/03/31