Medical Claims Analyst
AI job insight
Afia Concept Claims Settling Agency seeks a full-time Medical Claims Analyst in Nairobi. The role reviews and adjudicates healthcare claims, verifies clinical documentation and benefits, and supports compliant, efficient claims processing.
- Full-time position in Nairobi focused on medical claims adjudication.
- Reviews inpatient, outpatient, dental, optical, pharmacy and reimbursement claims.
- Assesses clinical records, ICD-10/ICD-11 codes, invoices and pre-authorizations.
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Afia Concept Claims Settling Agency seeks a full-time Medical Claims Analyst in Nairobi. The role reviews and adjudicates healthcare claims, verifies clinical documentation and benefits, and supports compliant, efficient claims processing.
- Full-time position in Nairobi focused on medical claims adjudication.
- Reviews inpatient, outpatient, dental, optical, pharmacy and reimbursement claims.
- Assesses clinical records, ICD-10/ICD-11 codes, invoices and pre-authorizations.
- Evaluates medical necessity against clinical guidelines and utilization protocols.
- Works with Care Management, Provider Relations, Finance and Client Success teams.
- Requires a BA/BSc/HND, Diploma or Professional Certificate.
- Employer warns candidates never to pay for notarisation, certificates or assessments.
AI job guide
Use this guide to check salary signals, requirements, documents, application steps and safety before you apply.
AI salary guide
Source salary availableThe source lists Never pay for any notarisation, certificate or assessment as part of any recruitment process. Confirm the final pay, benefits, contract terms and allowances directly with the employer before accepting an offer.
Can you qualify for this role?
- UnclearRelated work experienceThe text mentions experience, but the exact level should be confirmed at source.
- RequiredEducation or certification mentioned in the postThe captured text mentions education, a diploma, certificate, or licence.
- PreferredPractical evidence in entregador, technology, financeThe tags and summary point to skills connected with this role.
- RequiredAvailability to work in NairobiThe vacancy is associated with this location.
- UnclearComfort with the Full Time contract termsConfirm hours, duration, probation and benefits at the original source.
Documents to prepare
- Likely requiredUpdated CV
- Role specificCover letter or short employer message
- OptionalProfessional references
- Role specificAcademic or professional certificates
- VerifyID or passport only after verifying the employer
Application tips for this job
- Place your strongest Medical Claims Analyst evidence in the first half of your CV.
- In your cover letter or employer message, connect your experience to Afia Concept Claims Settling Agency (ACS) and the role in Nairobi.
- Add concrete examples related to entregador, technology, finance, ideally with measurable outcomes or clear responsibilities.
- Follow the instructions from MyJobMag Kenya; avoid sending documents to unofficial contacts or copied links.
- Confirm the deadline, interview location and employer contact before sharing personal documents.
- Prepare a polite question about pay, benefits and contract terms for later interview stages.
Source and safety check
- MyJobMag Kenya
- Original source link available
- Application method is clear
- Deadline not specified
- No major risk signal was detected in the captured text.
Never pay for interviews, shortlisting, medical checks, uniforms, or job placement. Confirm every application at the original source before sharing personal documents. Report suspicious listing.
Interview preparation
- What experience makes you a strong fit for this Medical Claims Analyst role in entregador, technology?
- How have you handled responsibilities similar to those in this job post?
- Are you available to work in Nairobi under the listed contract or schedule?
- Prepare examples with clear responsibilities, tools used and measurable outcomes.
- Review the source and research Afia Concept Claims Settling Agency (ACS) before the interview.
Ask what the first priorities will be in the role and how success will be measured.
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Original source description
Never pay for any notarisation, certificate or assessment as part of any recruitment process. When in doubt,
contact us
Afia Concept Claims Settling Agency (ACS) is a forward-thinking healthcare consulting firm operating in East Africa, with headquarters in Nairobi, Kenya. Established to bridge the gap between healthcare infrastructure and accessible, high-quality services, ACS offers end-to-end solutions in healthcare facility design, health financing advisory, digital health, and operational management.
View All Jobs at Afia Concept Claims Settling Agency (ACS)
Medical Claims Analyst
Job Type: Full Time
Qualifications
BA/BSc/HND
,
Diploma
,
Professional Certificate
Diploma or Bachelor's Degree in Nursing, Clinical Medicine, Health Records & Information Management, Public Health, or a related health sciences field.
Added Advantage
Professional qualifications in AIIK, ACII, or Certificate in Insurance.
Familiarity with managed care concepts, utilization review, and medical tariff structures applicable in the Kenyan market.
Experience working with a claims management system, TPA platform, or health insurance adjudication software.
Understanding of the Insurance Act (Cap. 487), IRA guidelines, and the Kenya Data Protection Act, 2019.
Check how your CV matches this job
Method of Application
- Interested and qualified? Go to
- Afia Concept Claims Settling Agency (ACS) on www.acs.co.ke
- to apply
- Build your CV for free.
- Download in different templates.
Experience
Location: Nairobi
Job Field: Data, Business Analysis and AI
,
ICT / Computer
,
Medical / Healthcare
Role Purpose
The Medical Claims Analyst role is responsible for the accurate, timely, and compliant adjudication of medical claims submitted by healthcare providers on behalf of scheme members. It requires someone who can interpret medical documentation, apply benefit rules, identify anomalies, and contribute to the continuous improvement of ACS's claims processes. The analyst works closely with the Care Management, Provider Relations, Finance, and Client Success teams to ensure claims are processed fairly, efficiently, and in accordance with contracted terms and regulatory requirements.
Key Accountabilities
- Claims Adjudication, Medical Review & Utilization Management
- Review, assess, and adjudicate inpatient, outpatient, dental, optical, pharmacy, and reimbursement claims in accordance with scheme benefits, policy terms, exclusions, limitations, and contractual provider agreements.
- Verify member eligibility, active cover status, benefit availability, and service validity before processing claims.
- Review clinical documentation including medical notes, diagnoses, ICD-10/ICD-11 codes, procedure codes, laboratory and radiology reports, discharge summaries, prescriptions, operative notes, and itemized invoices to validate claims accuracy.
- Assess medical necessity and appropriateness of services, procedures, investigations, medications, admissions, and length of stay against clinical guidelines and ACS utilization management protocols.
- Review claims against approved pre-authorizations to confirm alignment with approved treatment plans, authorized services, and applicable limits, escalating variances where required.
- Claims Quality Assurance, Accuracy & Cost Management
- Review provider bills to identify overcharging, duplicate billing, incorrect tariffs, unsupported services, unbundled charges, and incorrect benefit application.
- Confirm that billed services are supported by medical documentation and match the diagnosis and treatment provided.
- Apply agreed provider tariffs, negotiated rates, package rates, discounts, and payment arrangements when processing claims.
- Identify unnecessary costs and apply appropriate claims controls to support cost management.
- Identify savings opportunities through claims review, billing corrections, tariff application, and utilization management.
- Fraud, Waste & Abuse Detection
- Identify possible fraud, waste, and abuse, including fake claims, inflated bills, duplicate claims, unnecessary services, and billing for services not provided.
- Review provider and member claim patterns to identify unusual or suspicious activities.
- Escalate suspected fraud, waste, and abuse cases in line with ACS escalation procedures.
- Support investigations by providing claim reviews, documentation, and utilization reports.
- Support improvement of claims rules and system controls to prevent fraud and inappropriate payments.
- Provider Management, Stakeholder Engagement & Query Resolution
- Respond to provider queries on claim status, approvals, rejections, payment issues, and documentation requirements within agreed timelines.
- Confirm provider claims are billed according to agreed tariffs, packages, discounts, and contractual terms.
- Work with the Provider Relations team to resolve billing errors, tariff issues, and recurring provider concerns.
- Work with Care Management, Finance, and Client Success teams to resolve claims-related issues and improve service delivery.
- Provide feedback on provider billing trends and areas requiring improvement.
- Claims Reporting, Analytics & System Management
- Track and report on savings achieved through claims edits, overbilling recoveries, and application of contracted rates versus billed charges.
- Support scheme reporting, reconciliation, and claims performance reviews.
- Ensure accurate entry and maintenance of claims information in the claims management system.
- Participate in testing system improvements, automated claims rules, and workflow enhancements.
- Key Performance Indicators
- Care Plan Management and Member Satisfaction
- Pre-Authorization Turnaround Time
- Clinical Case Review Accuracy
- Hospital Admission Management
- Discharge Planning Effectiveness
- Chronic Disease Management Outcomes
- Escalation and Critical Case Management
- Healthcare Utilization Management
- Clinical Documentation Quality
- Provider Engagement and Collaboration
- Compliance with Clinical Protocols
- Case Resolution Timeliness
- Reporting Accuracy and Timeliness
- Data Protection and Confidentiality Compliance
- Cost Containment and Care Optimization