At a glance
- Closing date
- The listing does not give one. Employers often close early when they have enough applicants, so apply soon.
- Where
- Nairobi, Kenya
- How to apply
- On myjobmag.co.ke, where the employer takes applications.
- Similar roles
- 31 other open Insurance roles on the Kenya board right now.
- This employer
- ICEA Lion Group has 11 open roles on RezSync.
Role Overview
The Medical Clinical Claims Analyst & Adjudicator will be responsible for the clinical vetting, medical necessity assessment, and end-to-end adjudication of inpatient and outpatient claims. The role ensures prompt, equitable, and accurate claim settlements in strict compliance with policy terms, medical benefit structures, standard clinical guidelines, and regulatory requirements. By combining clinical knowledge with insurance operations, the role holder will act as a frontline defender against fraud, waste, and abuse (FWA) while safeguarding client satisfaction and provider / TPA relations.
Key Responsibilities
Clinical Adjudication & Claims Assessment
Review, audit, and adjudicate incoming outpatient, inpatient, maternity, dental, optical, and specialized medical claims against member policy covers, exclusions, and benefit limits.
Validate clinical necessity, diagnostic appropriateness, ICD-10/11 coding, and procedural alignment (CPT codes) for billed treatments, diagnostics, surgeries, and pharmaceuticals.
Appraise pre-authorization requests, elective admissions, and specialist referrals to ensure adherence to clinical pathways and pre-agreed fee schedules.
Execute timely approvals, partial settlements, or claim repudiations with clear, clinically substantiated rationales communicated to providers and clients.
Cost Containment, Fraud Mitigation & Provider Audits
Detect, investigate, and flag patterns of over-servicing, unbundling, up-coding, duplicated billing, and phantom claims across provider networks.
Conduct continuous provider account reconciliations, billing audits, and contentious bill reviews.
Negotiate discounted package pricing, fee concessions, and settlement terms with empanelled healthcare facilities for high-cost admissions or out-of-network claims.
Data Analytics & Reporting
Track key operational metrics, including claim turnaround time (TAT), loss ratios, cost per event, and provider utilization trends.
Extract and analyze claims data to identify emerging epidemiological patterns, high-cost claimants, and provider billing outliers.
Prepare periodic technical claims reports for internal management, underwriting, actuarial teams, and statutory returns (such as IRA compliance schedules).
Provider & Stakeholder Relationship Management
Act as a clinical liaison between ICEA LION General, panel healthcare providers (hospitals, clinics, pharmacies, diagnostic centers), brokers, and corporate scheme administrators.
Facilitate swift dispute resolution on contentious claims, billing discrepancies, and policy interpretations.
Provide clinical and policy feedback to underwriting teams to refine policy wordings, benefit limits, and risk underwriting guidelines.
Key Performance Indicators (KPIs)
Turnaround Time (TAT): 95%+ of claims vetted and adjudicated within agreed internal and regulatory SLAs.
Adjudication Accuracy: Claim leakage error rate maintained below established departmental thresholds.
Cost Containment Savings: Demonstrated quantifiable savings through clinical intervention, tariff enforcement, and FWA prevention.
Provider Reconciliation: Minimal aging of contentious provider / TPA reconciliations and disputed accounts.
Requirements for the role:
Bachelor’s Degree or Diploma in Nursing (e.g., BScN, KRCHN), Clinical Medicine and Community Health, or Pharmacy.
Active practicing license and valid registration with the relevant statutory body (e.g., Nursing Council of Kenya, Clinical Officers Council, or Pharmacy and Poisons Board).
Certificate of Proficiency in Insurance (COP) or progress toward professional certifications like AIIK (Insurance Institute of Kenya) or ACII (Chartered Insurance Institute). (Added Advantage)
Training or certification in standard medical coding: ICD-10 / ICD-11 (diagnostic) and CPT (procedural). (Added Advantage)
Minimum 5 years in a busy health insurance firm, Third Party Administrator (TPA), or hospital credit/billing department handling medical claims vetting, pre-authorizations, and care management.
Demonstrated skill in identifying unbundling, up-coding, phantom billing, and unnecessary over-servicing.
Hands-on experience auditing itemized hospital bills, negotiating procedure packages, and managing disputed claims with provider networks.
Proficiency in core claims management information systems (CMIS) and advanced Microsoft Excel (pivot tables, lookup functions, data auditing) for monitoring loss ratios, costs per event, and provider utilization trends.
Minimum qualifications
BA/BSc/HND , Professional Certificate
How to apply
Use the link(s) below to apply on company website.
Pension Support Assistant
Trust Consultant
Manager 1: Reporting & Financial Controls
Associate II: Reporting
Associate II : Medical Claims & Adjudicator
https://www.myjobmag.co.ke/apply-now/1381626
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