| Position: |
CLAIMS ANALYST -2 POSTS (FOR AN INTERNATIONAL MEDICAL INSURANCE SERVICE PROVIDER) |
| Employer: |
AN INTERNATIONAL MEDICAL INSURANCE SERVICE PROVIDER |
| Ref No: |
SGK-CA-08-2025 |
| Industry: |
INSURANCE |
| Job Category: |
SUPERVISORY |
| Town: |
NAIROBI |
| Country: |
KENYA |
| Date Posted: |
18/08/25 |
| Deadline: |
01/09/25 |
| Requirements: |
DEGREE IN RISK MANAGEMENT, ACTUARIAL SCIENCE, STATISTICS OR BUSINESS ADMINISTRATION OR RELATED FIELD.
DIPLOMA IN INSURANCE, NURSING, CLINICAL MEDICINE AND SURGERY, HEALTHCARE ADMINISTRATION, OR A RELATED FIELD IS AN ADDED ADVANTAGE.
GOOD KNOWLEDGE OF MEDICAL PROCEDURES, BILLING CODES, AND CLAIMS ADJUDICATION SYSTEMS.
|
| Experience: |
MINIMUM 2 YEARS OF EXPERIENCE IN HEALTH CLAIMS PROCESSING, PREFERABLY IN INTERNATIONAL MEDICAL INSURANCE.
EXPERIENCE WITH CLAIMS ADJUDICATION SYSTEMS AND AI-BASED CLAIMS TOOLS IS HIGHLY DESIRABLE. |
| Salary: |
KSHS. 55,000 - 70,000 PLUS COMPANY BENEFITS |
| Additional Attributes: |
CLAIMS ANALYST IS RESPONSIBLE FOR EVALUATING, PROCESSING, AND ADJUDICATING MEDICAL INSURANCE CLAIMS WITH ACCURACY AND EFFICIENCY. THE ROLE ENSURES TIMELY CLAIMS SETTLEMENT WHILE ADHERING TO POLICY TERMS, INTERNATIONAL AND LOCAL PROVIDER AGREEMENTS, AND REGULATORY GUIDELINES. CLAIMS ANALYST WORKS CLOSELY (OR COLLABORATES) WITH CLIENTS, MEDICAL PROVIDERS, AND INTERNAL TEAMS TO DELIVER A SEAMLESS AND PROFESSIONAL CLAIMS EXPERIENCE BY PERFORMING THE FOLLOWING RESPONSIBILITIES:-
IDENTIFY AND REPORT FRAUD OR IRREGULARITIES:-
MONITOR FOR SIGNS OF SUSPICIOUS ACTIVITY, MISREPRESENTATION, OR FRAUDULENT CLAIMS. ESCALATE ANY CONCERNS TO THE COMPLIANCE TEAM IN ACCORDANCE WITH INTERNAL PROTOCOLS.
DETERMINE CLAIM OUTCOME AND SETTLEMENT:-
BASED ON THE EVIDENCE AND COMPANY GUIDELINES, DECIDE WHETHER TO APPROVE, DENY, OR ADJUST THE CLAIM. CALCULATE APPROPRIATE SETTLEMENT AMOUNTS AND ENSURE THEY ALIGN WITH POLICY TERMS AND COMPANY STANDARDS.
UTILIZE DIGITAL TOOLS AND AI SYSTEMS:-
OPERATE CLAIMS MANAGEMENT SOFTWARE AND AI-ASSISTED PLATFORMS TO STREAMLINE PROCESSING, DETECT INCONSISTENCIES, AND IMPROVE DECISION MAKING. STAY OPEN TO EMBRACING NEW TECHNOLOGIES THAT ENHANCE CLAIMS HANDLING EFFICIENCY.
REVIEW AND ANALYSE CLAIMS DOCUMENTS:-
CAREFULLY EXAMINE SUBMITTED CLAIMS AND SUPPORTING DOCUMENTS SUCH AS MEDICAL RECORDS AND POLICYHOLDER STATEMENTS TO DETERMINE THE VALIDITY AND COMPLETENESS OF THE INFORMATION. REVIEW AND PROCESS MEDICAL INSURANCE CLAIMS ACCURATELY AND ON TIME.
DOCUMENT ALL CLAIM ACTIVITY:-
ACCURATELY RECORD ALL ACTIONS TAKEN, COMMUNICATIONS, AND DECISIONS IN THE CLAIM FILE. ENSURE RECORDS ARE COMPLETE, UPTODATE, AND COMPLIANT WITH REGULATORY AND AUDIT REQUIREMENTS.
COLLABORATE WITH CROSS FUNCTIONAL TEAMS:-
WORK CLOSELY WITH UNDERWRITERS, RISK ASSESSORS, CUSTOMER SERVICE, AND LEGAL TEAMS TO ENSURE CLAIMS ARE RESOLVED QUICKLY AND ACCURATELY WHILE MINIMIZING RISK TO THE COMPANY.
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