Medical Coder & National Terminology / Insurance Formulary Manager

Neotech Kenya Limited is a healthcare technology company focused on transforming healthcare delivery through digital innovation, clinical intelligence, health information exchange, and benefit management solutions. Our platforms support healthcare providers, insurers, government agencies, pharmacies, laboratories, and patients by enabling standardized healthcare data, terminology management, claims processing, and digital healthcare services. We are seeking a highly motivated Medical Coder & National Terminology / Insurance Formulary Manager to support clinical coding, healthcare terminology governance, formulary management, and interoperability initiatives across multiple healthcare systems and insurance schemes. Position Summary The Medical Coder & National Terminology / Insurance Formulary Manager will be responsible for ensuring accurate clinical coding, maintaining national and international healthcare terminologies, managing insurance formularies and benefit rules, supporting healthcare interoperability standards, and ensuring compliance with regulatory requirements. The role requires collaboration with clinical teams, insurance providers, government health agencies, pharmacists, and software development teams to maintain high-quality healthcare data standards. Primary Responsibilities: Medical Coding & Clinical Data Management • Assign accurate clinical codes using international coding standards including ICD-10, ICD-11, SNOMED CT, LOINC, CPT, HCPCS, ATC, and other approved healthcare terminologies. • Review patient records, clinical notes, laboratory results, imaging reports, prescriptions, and treatment documentation to ensure coding accuracy. • Apply coding conventions and official coding guidelines in accordance with regulatory and payer requirements. • Validate diagnosis, procedures, medications, and clinical documentation to ensure completeness and accuracy. • Identify coding inconsistencies, discrepancies, missing information, and documentation gaps and escalate appropriately. • Maintain coding quality, productivity, and turnaround times as defined by organizational KPIs and SLAs. • Support clinical audits, claims audits, utilization reviews, and quality assurance activities. • Ensure compliance with healthcare privacy, security, and data protection regulations. National Terminology Management • Manage and maintain national healthcare terminology repositories and mappings. • Administer healthcare code systems including: o ICD-10 and ICD-11 o SNOMED CT o LOINC o CPT o ATC Drug Classification o National Drug and Medical Device Catalogues o PPB Drug Registrations o Healthcare Facility and Provider Registries • Develop and maintain terminology mappings between different healthcare coding standards. • Support implementation and maintenance of Terminology Services and Terminology APIs. • Validate and update terminology datasets based on regulatory and clinical updates. • Coordinate terminology releases and version management activities. • Support healthcare interoperability initiatives including HL7 FHIR, HIE integrations, and national digital health programs. • Work with DHA, Ministry of Health, insurance companies, and healthcare stakeholders on terminology standardization initiatives. • Monitor changes to international standards and recommend implementation plans. Insurance Formulary & Benefit Management • Maintain and manage insurance medicine formularies across multiple insurers and healthcare schemes. • Configure and update formularies for: o Insurance companies o Government healthcare schemes o Employer medical schemes o Public healthcare programs • Manage medicine coverage rules, exclusions, restrictions, prior authorization requirements, and benefit limits. • Review and validate medication classifications using ATC codes and national drug registries. • Maintain mappings between formulary medicines, generic medicines, brands, and insurance coverage rules. • Support benefit management systems by maintaining: o Drug formularies o ICD diagnosis mappings o Procedure coverage rules o Benefit limits o Clinical validation rules o Preauthorization criteria • Collaborate with pharmacists, insurers, and clinical teams to update formulary policies. • Analyze formulary utilization trends and recommend optimization opportunities. • Ensure compliance with payer contracts, regulatory requirements, and clinical governance standards. Data Governance & Quality Assurance • Perform regular quality reviews of coding, terminology, and formulary datasets. • Develop and maintain documentation, SOPs, and governance frameworks. • Generate reports and dashboards related to coding accuracy, terminology usage, and formulary performance. • Support testing and validation of healthcare systems, APIs, and interoperability solutions. • Participate in system implementation, data migration, and healthcare digitization projects. General Responsibilities • Maintain confidentiality of patient and organizational data. • Collaborate with cross-functional teams including clinicians, pharmacists, insurers, business analysts, and software developers. • Support training and knowledge transfer activities related to coding, terminology, and formulary management. • Comply with company policies, procedures, and operational requirements. • Perform any other duties assigned by management in support of organizational objectives. Required Qualifications: • Bachelor's Degree in: o Medicine o Pharmacy o Nursing o Clinical Medicine o Health Records & Information Management o Biomedical Sciences o Life Sciences o Public Health o Health Informatics o Other relevant healthcare disciplines • Professional certification in one or more of the following is an added advantage: o AAPC (CPC, CPC-H) o AHIMA (CCS, CCS-P) o ICD-10 / ICD-11 Certification o SNOMED CT Certification o HL7 FHIR Certification o Health Informatics Certification Required Experience & Skills • Minimum 3 years of experience in medical coding, healthcare informatics, terminology management, formulary management, or health information systems. • Strong knowledge of: o ICD-10 and ICD-11 o SNOMED CT o LOINC o CPT o ATC Classification System o Healthcare interoperability standards (HL7/FHIR) o Insurance benefit management o Medical terminology and clinical documentation • Understanding of: o Human anatomy and physiology o Pathophysiology o Pharmacology and medication management o Insurance claims processing o Preauthorization workflows o Clinical decision support systems • Experience managing healthcare reference data, terminology repositories, or insurance formularies. • Familiarity with healthcare APIs, Health Information Exchanges (HIE), and digital health ecosystems. • Strong analytical, problem-solving, and data validation skills. • Excellent written and verbal communication skills. • Proficiency in Microsoft Office, healthcare information systems, and data management tools. Preferred Qualifications • Experience working with national health programs, government healthcare agencies, insurance companies, or healthcare technology platforms. • Experience managing large-scale medicine formularies and terminology datasets. • Knowledge of DHA, SHA, HIE, FHIR, and digital health interoperability frameworks. • Experience with healthcare data governance and regulatory compliance. • Familiarity with terminology servers, FHIR Terminology Services, and clinical knowledge management systems. Key Performance Indicators (KPIs) • Coding accuracy and productivity. • Terminology update and maintenance compliance. • Formulary accuracy and completeness. • Reduction in coding and formulary-related claim rejections. • Timely implementation of regulatory and terminology updates. • Data quality and interoperability compliance. • Stakeholder satisfaction and support effectiveness.