Job Ref. No: JHIL204

Position: Medical Claims Assessor

Role Purpose

The role holder will be required to assess and process medical claims accurately and efficiently, ensuring adherence to policies and regulatory requirements, while providing exceptional customer service

Key Responsibilities

Operational

• Review and assess medical claims for accuracy, completeness, and eligibility based on policy terms, medical guidelines, and coding systems.
• Apply comprehensive knowledge of medical terminology, diagnoses, procedures, and coding systems (e.g., ICD-10, CPT) to determine the validity of claims.
• Analyse medical records, invoices, and other relevant documentation to assess the appropriateness of reimbursement.
• Communicate effectively with healthcare providers, policyholders, and internal teams to gather additional information or clarify claim details.
• Adhere to predefined timelines and service level agreements for claims assessment and resolution.
• Maintain accurate records of claims processing activities and ensure confidentiality of sensitive information.
• Collaborate with internal teams, such as underwriting, finance, and customer service, to address claim-related queries and resolve issues.
• Participate in training programs to enhance knowledge of medical coding practices, industry regulations, and company policies.

Corporate Governance

• Ensure compliance with company policies, procedures, and regulatory guidelines throughout the claims assessment process.
• Maintain confidentiality and handle sensitive information in accordance with privacy laws and regulations.
• Adhere to ethical standards and conduct while dealing with confidential or sensitive matters.

Culture

• Engaging in ongoing professional development activities to enhance knowledge and skills in claims
• assessment, regulatory compliance, and corporate governance.
• Foster effective working relationships with internal stakeholders, such as underwriting,
• reconciliations, finance, and to ensure alignment and collaboration in claims activities.

Laws, Regulations, Company Policies & Regulatory Guidelines:

• Stay informed about applicable laws and regulations, including Anti-Money Laundering (AML) and
• Counter Financing of Terrorism (CFT) laws, as well as Data Protection laws.
• Ensure that your actions and activities align with these legal requirements; Understand and adhere to internal company policies, processes, and procedures.
• Promptly report any instances of non-compliance to management and the designated compliance officer.
• Take proactive measures to mitigate compliance risks within your role and department.
• Participate in training programs and awareness sessions organized by the company to enhance your understanding of compliance requirements.

Key Skills and Competencies

• Strong knowledge of medical terminology, diagnoses, procedures, and coding systems.
• Analytical and critical thinking skills to assess the validity and appropriateness of claims.
• Attention to detail and ability to maintain accuracy while processing complex information.
• Excellent communication and interpersonal skills to interact with internal and external stakeholders.
• Ability to work independently and manage time effectively to meet deadlines.
• Adaptability and flexibility to handle changing priorities and work in a fast-paced environment.
• Proficiency in claims assessment software and tools.
• Familiarity with medical coding systems such as ICD-10 and CPT.
• Understanding of insurance policies and coverage limitations.
• Knowledge of healthcare regulations and compliance requirements.
• Proficient in using Microsoft Office Suite (Word, Excel, PowerPoint).

Academic Qualifications

• Bachelor’s degree in a related field (e.g., healthcare administration, nursing, clinical medicine, and surgery).
• Relevant certifications in claims management or insurance.

Relevant Experience

• 3 years of working experience in a claims department in an insurance field.

How to Apply

If you are qualified and seeking an exciting new challenge, please apply via Recruitment@jubileekenya.com quoting the Job Reference Number and Position by 17th November 2025

Only shortlisted candidates will be contacted.