Provider Reconciliation Officer at Afia Concept Claims Settling Agency (ACS)

Key responsibilities

• Perform regular reconciliation of provider statements against adjudicated claims and payment records.
• Review provider accounts to identify discrepancies, overpayments, underpayments, duplicate payments, and unallocated transactions.
• Maintain accurate reconciliation schedules and supporting documentation.
• Review rejected and partially settled claims and ensure proper documentation.
• Ensure all payment records are accurately reflected in reconciliation reports.
• Collaborate with Claims and Finance teams to address payment variances.
• Maintain records of provider disputes and resolution actions.
• Ensure timely communication with providers regarding outstanding matters.
• Identify financial discrepancies and escalate material risks appropriately.
• Monitor ageing balances and unresolved reconciliation items.
• Support recovery of overpayments and identification of duplicate claims.
• Ensure compliance with reconciliation controls and financial procedures.
• Assist in prevention and detection of billing irregularities and fraudulent claims.
• Maintain professional working relationships with healthcare providers.
• Support initiatives aimed at improving provider satisfaction and payment transparency.
• Promote effective communication between providers and internal stakeholders.
• Facilitate resolution of provider concerns through collaborative engagement.
• Prepare daily, weekly, and monthly reconciliation reports.

Candidate requirements

• Location Nairobi
• Job Field Finance / Accounting / Audit &nbsp.
• Role Purpose
• The Provider Reconciliation Officer is responsible for ensuring accurate reconciliation of healthcare providers' accounts by validating claims, invoices, payments, recoveries, credit notes, and provider statements. The role plays a critical part in maintaining financial accuracy, supporting timely provider settlements, minimizing disputes, and fostering positive provider relationships.
• Within a Third-Party Administration (TPA) environment, the incumbent serves as a key liaison between healthcare providers, claims teams, medical teams, finance teams, and clients to ensure that provider accounts accurately reflect services rendered, approved claims, payments made, and outstanding balances. The role requires strong analytical skills, attention to detail, and a thorough understanding of healthcare claims processing and provider payment cycles.
• Key Accountabilities.
• Provider Account Reconciliation.
• Perform regular reconciliation of provider statements against adjudicated claims and payment records.
• Verify the accuracy of provider invoices, statements, remittances, and account balances.
• Match approved claims against payments made to healthcare providers.
• Review provider accounts to identify discrepancies, overpayments, underpayments, duplicate payments, and unallocated transactions.
• Investigate and resolve unidentified or unmatched transactions.
• Maintain accurate reconciliation schedules and supporting documentation.
• Claims and Payment Verification.
• Validate claims included in provider invoices prior to payment processing.
• Reconcile approved claims against contractual payment schedules and approved tariffs.
• Verify deductions, recoveries, reversals, and adjustments applied to provider accounts.
• Review rejected and partially settled claims and ensure proper documentation.
• Ensure all payment records are accurately reflected in reconciliation reports.
• Collaborate with Claims and Finance teams to address payment variances.
• Provider Query and Dispute Resolution.
• Respond promptly to provider enquiries relating to invoices, payments, deductions, recoveries, and account balances.
• Investigate provider disputes and reconciliation exceptions.
• Liaise with relevant internal departments to obtain supporting documentation and resolutions.
• Maintain records of provider disputes and resolution actions.
• Follow up on open reconciliation issues until closure.
• Ensure timely communication with providers regarding outstanding matters.
• Financial Control and Risk Management.
• Identify financial discrepancies and escalate material risks appropriately.
• Monitor ageing balances and unresolved reconciliation items.

Required skills