Claims Vetting and Processing Officer

Role Overview

This Claims Vetting and Audit position sits between medical providers, insured members, and the company’s claims operation. Day to day, the officer examines provider invoices and claim documents to confirm that services billed are covered, clinically justified, and charged at the correct contracted rate before any payment is released. The role matters because every valid claim paid promptly protects the company’s service reputation, while every invalid or inflated claim caught early directly reduces claims costs and helps keep loss ratios under control.

Key Responsibilities

• Review and audit provider invoices against policy terms, benefit limits, pre-authorization records, and agreed provider tariffs before payment is approved.
• Process allocated provider payments within set turnaround times, maintaining accurate records and preventing delays that could interrupt care for insured members.
• Apply cost-containment rules and contracted rates consistently, identifying overcharges, unbundled services, and items that fall outside cover.
• Detect suspicious, duplicated, or medically unsupported claims and escalate potential fraud for further investigation.
• Explain exclusions, deductions, and non-payment decisions to clients and service providers within agreed communication timeframes.
• Monitor claims experience and provider billing trends, preparing reports that support provider management, client retention, and management action.
• Negotiate provider discounts, document savings achieved, and participate in account reconciliation and sign-off for allocated providers.
• Respond to payment queries from providers and members, support improvements to claims vetting and payment systems, and contribute to departmental planning, meetings, committees, and medical business events.

Requirements & Qualifications

• Bachelor of Science in Nursing is required.
• Registration as a Kenya Registered Nurse (KRN) or Kenya Registered Community Health Nurse (KRCHN); a Clinical Medicine qualification is an added advantage.
• Minimum of one year of relevant experience in medical claims vetting, claims audit, provider billing, or a similar healthcare insurance role.
• Working knowledge of medical terminology, treatment protocols, billing codes, and the documentation needed to justify a claim.
• Familiarity with health insurance claims procedures, policy exclusions, pre-authorization, provider contracts, and reimbursement methods.
• Strong analytical skills to spot anomalies, fraud indicators, and cost leaks across large volumes of invoices.
• Confident negotiation and communication skills for dealing with providers, clients, and internal teams, plus good record-keeping and reporting ability.
• Ability to work under pressure, meet payment deadlines, and use claims management systems and spreadsheets accurately.