Medical Claims Analyst Job in Kenya

Medical Claims Analyst

Job description.

Reporting to Head – Benefits, the role holder will be responsible for engagement with medical providers & insurance for case management of the medical scheme, engage with medical service providers to interrogate the nature and costing of medical services rendered to members before claims processing, engaging with insurance underwriters on addition and deletion of members as well as reconciliation with credit control teams of the various providers in the panel as well as effective and efficient administration of staff medical claims submitted for reimbursement.

The Role

Specifically, the successful jobholder will be required to:

  • Validate authenticity and completeness of the information and attachments on all medical claims presented by staff members for reimbursement whilst ensuring strict adherence to set guidelines and TAT.
  • Review all medical/surgical billings for reasonable and necessary charges as well as evaluate claims referred for medical management and make recommendations for follow-up, further investigation or documentation as necessary and also vet and analyse medical claims as per scope of cover whilst ensuring strict adherence to set guidelines and TAT
  • Correctly read and assess medical documents to either approve or deny payment of medical claims and accurately approve the e-payment files.
  • Maintain accurate medical records, preparation of informative management claims reports, administer the bank funded Out-patient medical scheme and update staff medical statements and ensuring all utilizations are captured on a timely basis.
  • Ensure reconciliation of medical providers’ bills & accounts on an ongoing basis or on demand including visits to providers; recommend appropriate payment of dispute of billing, as necessary.
  • Ensure timely admission of new staff and dependants to in & out-patient medical schemes and prepare utilization reports as required by member / client.
  • Provide professional assistance to all the staff members/dependents with chronic ailments and facilitating follow up in specialists’ clinics.
  • Arrange for emergency evacuations for medical scheme members’ country wide.
  • Be the point of contact for staff members and other stakeholders on health matters/issues as well as ensure that staff members are educated especially on lifestyle issues and also provide staff training and member education on quality health care cost containment and utilization.
  • Attends mediations and other hearings to inform and defend the cost containment procedures, guidelines and decisions rendered.

Skills, Competencies and Experience

The successful candidate will be required to have the following skills and competencies:

  • A Bachelor’s degree in a medical/Health related field i.e. Nursing/ Clinical Medicine/ Pharmacy/ Medical Laboratory etc.
  • At least 3 years’ experience in a busy Health Insurance environment with Claims Vetting & Care management. Experience in insurance and health sector is an added advantage.
  • Knowledge of Fraud Risks associated with medical claims and experience in Medical reconciliation.
  • Computer literate and familiar with standard office software applications.
  • Team player with strong communication, interpersonal and persuasive skills with a strong ability to build and maintain strong working relationships with a wide range of internal and external stakeholders.
  • Attentive to detail, good planning and organization skills with the ability to deliver effectively under strict deadlines. Maintains confidentiality and integrity of all information in their possession.

How to Apply

If you believe you fit the job profile, please email your application enclosing detailed Curriculum Vitae to indicating the job reference number MCA/HRAD/2023 by Tuesday 9th May, 2023.