Medical Claims Analyst at Afia Concept Claims Settling Agency (ACS)

Key responsibilities

• 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.
• 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.
• Review claims against approved pre-authorizations to confirm alignment with approved treatment plans, authorized services, and applicable limits, escalating variances where required.
• Review provider bills to identify overcharging, duplicate billing, incorrect tariffs, unsupported services, unbundled charges, and incorrect benefit application.
• 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.
• 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.
• Support investigations by providing claim reviews, documentation, and utilization reports.
• Support improvement of claims rules and system controls to prevent fraud and inappropriate payments.
• Provide feedback on provider billing trends and areas requiring improvement.
• Support scheme reporting, reconciliation, and claims performance reviews.
• Ensure accurate entry and maintenance of claims information in the claims management system.
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Candidate requirements

• Location Nairobi
• Job Field Data, Business Analysis and AI &nbsp, ICT / Computer &nbsp, Medical / Healthcare &nbsp.
• 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.

Required skills