Role Overview
Role Overview
The Medical Clinical Claims Analyst & Adjudicator is responsible for clinical vetting, medical necessity assessment and end-to-end adjudication of inpatient and outpatient claims.
The role ensures prompt, equitable and accurate claim settlements in compliance with policy terms, medical benefit structures, clinical guidelines and regulatory requirements.
The position combines clinical expertise with insurance operations to detect and prevent fraud, waste and abuse (FWA) while maintaining client satisfaction and strong provider/TPA relationships.Key ResponsibilitiesClinical Adjudication & Claims Assessment
Key Responsibilities
Review, audit and adjudicate outpatient, inpatient, maternity, dental, optical and specialized medical claims against policy covers, exclusions and benefit limits.
Validate clinical necessity, diagnostic appropriateness, ICD-10/11 coding and CPT procedural coding for treatments, diagnostics, surgeries and pharmaceuticals.
Appraise pre-authorization requests, elective admissions and specialist referrals to ensure adherence to clinical pathways and approved fee schedules.
Execute timely approvals, partial settlements or claim repudiations with clear, clinically supported justifications communicated to providers and clients.Cost Containment, Fraud Mitigation & Provider Audits
Detect, investigate and flag patterns of over-servicing, unbundling, up-coding, duplicate billing and phantom claims within provider networks.
Conduct provider account reconciliations, billing audits and reviews of disputed medical bills.
Negotiate discounted package pricing, fee concessions and settlement arrangements with empanelled healthcare providers for high-cost admissions and out-of-network claims.Data Analytics & Reporting
Monitor operational metrics including claim turnaround time (TAT), loss ratios, cost per event and provider utilization trends.
Analyze claims data to identify epidemiological trends, high-cost claimants and provider billing outliers.
Prepare technical claims reports for management, underwriting, actuarial teams and regulatory reporting purposes.Provider & Stakeholder Relationship Management
Act as a clinical liaison between ICEA LION General, healthcare providers, brokers and corporate scheme administrators.
Facilitate resolution of disputed claims, billing discrepancies and policy interpretation matters.
Provide clinical and policy feedback to underwriting teams to improve policy wording, benefit limits and risk underwriting (adsbygoogle=window.adsbygoogle||[]).push({});guidelines.Key Performance Indicators (KPIs)
Key Performance Indicators (KPIs)
Turnaround Time (TAT): Achieve 95% or more claims adjudication within agreed service-level timelines.
Adjudication Accuracy: Maintain claim leakage error rates below established departmental thresholds.
Cost Containment Savings: Deliver measurable savings through fraud prevention, tariff enforcement and clinical intervention.
Provider Reconciliation: Maintain minimal aging of disputed provider and TPA accounts.Requirements for the Role
Requirements for the Role
Bachelor’s Degree or Diploma in Nursing (BScN, KRCHN), Clinical Medicine and Community Health, or Pharmacy.
Valid practicing licence and active registration with the relevant statutory body, such as the Nursing Council of Kenya, Clinical Officers Council or Pharmacy and Poisons Board.
Certificate of Proficiency in Insurance (COP) or progress toward AIIK or ACII professional qualifications will be an added advantage.
Training or certification in ICD-10/ICD-11 diagnostic coding and CPT procedural coding will be an added advantage.
Minimum five (5) years' experience in a health insurance company, Third Party Administrator (TPA), or hospital billing/credit department handling claims adjudication, pre-authorizations and care management.
Demonstrated ability to identify unbundling, up-coding, phantom billing and unnecessary over-servicing.
Hands-on experience auditing itemized hospital bills, negotiating procedure packages and managing disputed provider claims.