Medical Claims Analyst

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

Qualifications

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.