Claims Assurance Officer - Embakasi at Avenue Healthcare

Main Purpose of the Job- (Job Summary)

• To ensure accurate and complete documentation for insurance and direct credit outpatient (OP) claims, minimize payer rejections, and enhance revenue assurance at the point of service through effective coordination between the reception, medical, and credit teams.

Main Responsibilities

Claims Documentation & Assurance

• Verify completeness and accuracy of insurance documentation prior to service delivery.
• Ensure insurance and patient details are correctly entered in the system.
• Validate pre-authorizations, NHIF codes, QR codes, diagnosis, and required claim attachments.

Front Office Oversight

• Supervise client service teams to ensure compliance with billing and documentation SOPs.
• Conduct ongoing training on insurance procedures, documentation standards, and system updates.

Rejection Prevention

• Analyze claim rejection trends and address root causes.
• Identify high-risk claims and escalate incomplete or inconsistent documentation for immediate resolution.

Interdepartmental Coordination

• Act as liaison between clinical, reception, and finance departments to ensure seamless documentation flow.
• Coordinate with insurance providers for clarifications or additional documentation needs.

Reporting & Audit

• Prepare daily and weekly reports on documentation compliance, rejection metrics, and flagged claims.
• Support internal audits and help implement corrective action plans to improve claims quality.

Financial & Operational Oversight

• Monitor invoicing reports, banking transactions, and Oracle purchases.
• Assist in cost optimization initiatives and ensure inventory accuracy.

Customer Experience

• Resolve patient concerns regarding billing and documentation professionally.
• Support a patient-first approach by ensuring clarity and transparency in the billing process.
• Perform any additional duties as assigned by management to support the revenue assurance function.

Key Deliverables of this position

• 100% accuracy and completeness of insurance and credit documentation before delivery of service.
• Reduction in claim rejections through proactive documentation checks and SOP compliance.
• Effective coordination across departments to ensure timely claims submission and revenue assurance.

Essential   

• Higher Diploma or Diploma in Health Records, Business Administration, or a related field.

Desirable

• CPA, ACCA, Diploma in accounting or any other relevant training in accounting, relevant bachelor’s degree, or a related field.

Work Experience & Skills

Essential   

• Minimum 3 years of experience in a medical billing/revenue cycle role, preferably in a hospital or insurance setting.

Desirable

• Knowledge of medical insurance procedures in Kenya (including SHA/SHIF, private insurance payers, etc.).

Key Competencies

Essential 

• Knowledge of medical billing software and EMR systems
• Strong attention to detail and accuracy
• Problem-solving and critical thinking abilities
• Excellent communication and interpersonal skills

Desirable 

• Ability to work in a fast-paced environment and under pressure