Diploma or Bachelor's Degree in Nursing, Clinical Medicine, Health Records & Information Management, Public Health, or a related health sciences field.
Minimum of 2 years' relevant experience in medical insurance administration, provider relations, or healthcare scheme management, preferably within an insurance company, brokerage firm, TPA, or medical service provider network.
Demonstrated hands-on experience reviewing clinical documentation and adjudicating medical claims is required.
Experience with both inpatient and outpatient claims is preferred.
Clinical & Coding Proficiency: Ability to interpret medical records, ICD-10 diagnoses, CPT procedure codes, and itemized provider bills with sufficient clinical literacy to assess appropriateness, accuracy, and completeness.
Claims Adjudication Knowledge: Sound understanding of health insurance policy terms, benefit structures, excesses, co-payments, exclusions, and waiting periods, and the ability to apply these consistently and correctly across a high volume of claims.
Fraud & Anomaly Detection: Keen eye for overbilling, upcoding, unbundling, duplicate claims, and fraud indicators, with the analytical discipline to document findings clearly and escalate appropriately.
Accuracy & Attention to Detail: Meticulous approach to reviewing documentation and making adjudication decisions, with a low error tolerance and a commitment to getting every claim right.
Communication & Stakeholder Management: Clear, professional written and verbal communication for interacting with providers, members, and internal teams, particularly when delivering rejection decisions or resolving disputes.
Added Advantage: Professional qualifications in AIIK, ACII, or Certificate in Insurance.
Added Advantage: Familiarity with managed care concepts, utilization review, and medical tariff structures applicable in the Kenyan market.
Added Advantage: Experience working with a claims management system, TPA platform, or health insurance adjudication software.
Added Advantage: Understanding of the Insurance Act (Cap. 487), IRA guidelines, and the Kenya Data Protection Act, 2019.
Application deadline2 Nov 2026
GK
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