Tariff File Manager

Patient Services

The Tariff File Manager is the group custodian of the Busamed Tariff Guide, tariff, billing-rule and reimbursement master data used across Busamed hospitals. The role is responsible for obtaining, interpreting, validating, loading, testing, releasing and monitoring annual and ad hoc tariff changes, funder-specific agreements and payment arrangements. The role also supports the preparation of Alternative Reimbursement Models (ARMs) through detailed service, utilisation and financial analysis, informed by industry trends, funder reimbursement developments and relevant healthcare innovation. This includes hospital tariff and procedure codes, item codes, modifiers, units, conversion factors, NAPPI-linked products, fixed fees, per diems, case rates, global fees, stop-loss rules and other alternative reimbursement arrangements. The role ensures that approved contractual terms are implemented consistently and on time across all facilities, supported by controlled change management, complete audit trails and post-implementation validation.

• Relevant Diploma or Degree in Information Management, Healthcare Administration, Finance, Business, Information Technology or a related field.
• Minimum five years relevant experience in South African private healthcare billing, medical scheme claims, tariff management or revenue-cycle administration, including direct experience in tariff-file or billing-rule maintenance.
• Sound knowledge of hospital tariff structures, procedure and item codes, ICD-10, NAPPI, modifiers, units, conversion factors, scheme and network rates, and alternative reimbursement arrangements
• Practical understanding of fixed fees, per diems, case rates, global fees, stop-loss provisions, exclusions, funder-specific billing rules and Alternative Reimbursement Models (ARMs).
• Working knowledge of the Medical Schemes Act, claims requirements, managed care arrangements and private healthcare reimbursement processes.
• Advanced Microsoft Excel capability, including large-file reconciliation, lookups, pivot tables, data validation, scenario modelling and financial-impact analysis.
• Ability to interpret contracts and tariff schedules accurately and convert them into clear system and operational requirements.
• Ability to undertake or coordinate detailed service analysis and translate utilisation, costing and reimbursement data into robust ARM and tariff recommendations.
• Strong analytical, problem-solving, written and verbal communication, stakeholdermanagement and report-writing skills.
• High level of accuracy, integrity, confidentiality, accountability and the ability to work independently under tight annual and ad hoc deadlines.

• Experience in a multi-facility hospital group, SAP healthcare billing, SQL/Power BI, formal clinical coding, value-based care or ARM modelling is advantageous.
• Experience in formal change control, version management, documentation, quality assurance and audit support.
• Hands-on experience with an enterprise hospital information and billing system, preferably SAP, including master-data maintenance, system testing and user acceptance testing.

Tariff Exception Investigation & Corrective Action

• Receive tariff-related rejection, short-payment, overpayment, under-billing or incorrect patient-liability matters formally referred by the Debtors Supervisor for technical investigation.
• Determine whether the cause relates to tariff master data, contractual rates, billing rules, modifiers, units, effective dates or system configuration and provide documented findings and recommendations.
• Implement approved tariff or billing-rule corrections through the required change-control, testing and release process and validate the production outcome.
• Provide the investigation outcome and corrective action back to the Debtors Supervisor, who retains accountability for the rejection/query register, funder follow-up and final account closure.
• Escalate material or systemic tariff risks to the Group Funder Relations Manager and monitor whether corrected tariff defects recur.

New Services, Products & Code Onboarding

• Govern the creation of new charge codes for procedures, wards, equipment, medicines, consumables, implants and prostheses before operational go-live.
• Confirm that required clinical, procurement, pharmacy, finance and management approvals are in place and that the applicable NAPPI, procedure or internal code has been verified.
• Validate cost, selling price, mark-up methodology, funder reimbursement treatment and billing rules before the new item or service is activated. 
• Review and deactivate obsolete or replaced codes in a controlled manner without compromising historical billing records.

Compliance, Risk, Audit & Document Control

• Ensure tariff and billing-rule maintenance is aligned with applicable medical scheme legislation, funder rules, contracts, industry coding standards and Busamed policies.
• Maintain audit-ready records of source files, approvals, testing, sign-off, effective dates, version changes and implementation results.
• Support internal, external and funder audits, respond to tariff-related findings and monitor agreed corrective actions to completion.
• Identify and report tariff, access-control, data-integrity and revenue risks, and protect confidential commercial and claim information.

Reporting, Analytics & Performance Monitoring

• Prepare regular management reporting on tariff changes, implementation status, outstanding funder files, defects, ARM development activity, financial impact and tariffrelated exception referrals.
• Monitor performance measures including on-time implementation, first-time accuracy, post-load defects, turnaround time for technical tariff investigations, audit findings and value recovered or protected.
• Analyse reimbursement trends and recurring tariff/payment variances to support pricing decisions, budgeting, contract reviews, ARM development and revenue-cycle improvement.
• Provide clear recommendations and escalate overdue or high-risk items to the Group Funder Relations Manager.

Stakeholder Support, Training & Knowledge Management

• Act as the central point of contact for tariff-file, billing-rule and payment-arrangement queries across the group.
• Issue clear implementation communications and provide practical guidance to billings, case management, credit control, finance and hospital teams.
• Develop and maintain standard operating procedures, control sheets, reference guides, change logs, training material and handover documentation.
• Provide training and post-implementation support whenever new tariffs, rules, products or payment arrangements are introduced.

Business Continuity & Service Delivery

• Maintain an up-to-date tariff calendar, dependency tracker and contingency plan for year-end and other time-critical implementations.
• Ensure that critical source files, approvals, test evidence and working documents are stored in the approved shared location and can be accessed during absence or system disruption. 
• Prioritise urgent changes according to financial and operational risk and communicate
  delays, dependencies and interim controls promptly.