Medical Claims Officer at Tenwek Hospital

Job Purpose

• The Medical Claims Officer will be responsible for the accurate preparation, processing, and follow-up of all hospital claims to insurance companies, Social Health Authority (SHA), and other third-party payers in line with signed MoUs and contracts. The role ensures claims are properly documented, submitted on time, and reconciled to minimize the hospital’s financial exposure and enhance revenue collection.

Key Responsibilities
Claims Management

• Prepare, review, and submit all hospital claims to insurance companies, SHA, and other contracted third parties within stipulated timelines.
• Ensure claims are prepared in accordance with signed MoUs, contracts, and prevailing guidelines.
• Verify accuracy and completeness of patient information, medical records, coding, and billing before submission.
• Track and follow up on pending claims, rejections, and underpayments to ensure timely settlement.

Documentation & Compliance

• Maintain accurate and up-to-date claims records, databases, and filing systems.
• Ensure adherence to all regulatory, hospital, and insurer requirements.
• Liaise with internal stakeholders (Clinical, Billing, Records, and ICT departments) to resolve claimrelated queries.
• Ensure compliance with SHA/insurance reporting and audit requirements.

Financial Accountability

• Reconcile claims submitted versus payments received and highlight variances.
• Identify and escalate financial exposure risks arising from delayed, rejected, or disputed claims.
• Support the Finance Manager in revenue analysis, reporting, and forecasting based on claims performance.

Stakeholder Engagement

• Act as the key contact between the hospital and insurance providers/SHA on claims-related matters.
• Work closely with the Finance Manager to negotiate and review claims settlement processes.
• Provide regular updates and reports on claims status to management.

Qualifications & Experience

• Bachelor’s degree in Finance, Accounting, Business Administration, or related field.
• Diploma in Clinical Medicine & Surgery or Diploma in Community Nursing
• Professional certification in Medical Billing & Coding, Health Economics, Health Management
• Systems or equivalent is an added advantage.
• Minimum of 3 years’ experience in medical claims management, billing, or healthcare finance (hospital setting preferred).
• Knowledge of Social Health Authority guidelines, insurance claims processes, and hospital billing systems.