ABOUT CAREPAY:
In 2015, the CarePay platform launched the mobile health wallet under the brand M-TIBA in Kenya. Combining mobile technology and -money so people could save up for future hospital expenses. Since then the platform grew to become the digital connector between the healthcare payers, providers, and members. Covering the end-to-end health insurance journey while always keeping the individual's perspective in mind first. The platform improves the way money flows through the healthcare system, lowering the costs society must pay to get access to good quality healthcare. CarePay is at the forefront of revolutionary technological and social impact within healthcare, improving the lives of millions around the world.
In 2019, CarePay raised $45 million in growth capital in its Series A financing round, becoming one of the best funded start-ups in Africa in 2019. Quickly after, the company was internationally recognized as #7 on Fortune’s Change the World 2020 list alongside Alibaba, Paypal and Zoom.Currently, CarePay has over 4.8 million people registered, 20+ Payers and 5,000+ healthcare providers connected to their platform. Following the success of M-TIBA in Kenya, CarePay has established its headquarters in Amsterdam, with the aim of scaling the platform to other countries. The company has already begun its international expansion.
MAIN PURPOSE OF THE JOB:
The Junior Claims Assessor will have the responsibility of ensuring that medical claims and cases are vetted and that they meet the set objectives for a given project. The position will also involve giving detailed reporting on all the general findings from the claims or cases vetted with the aim of improving project outcomes as well as enhancing system functionality.
KEY DUTIES AND RESPONSIBILITIES:
Claims Assessment and Adjudication
- Assess submitted claims for accuracy, eligibility, policy compliance and clinical appropriateness.
- Apply deductions, exclusions, limits, co-payments, and negotiated rates in line with scheme rules and contracts.
- Identify savings opportunities and ensure claims are processed accurately and within agreed timelines.
- Escalate unclear, high-cost, suspicious or non-standard claims for further review.
Cost Control and Savings Management
- Review claims to identify excessive billing, non-payable items, duplicate charges, and inappropriate utilization.
- Recommend or apply cost-saving interventions while maintaining fairness and clinical appropriateness.
- Support initiatives aimed at reducing claims leakage, waste, fraud, and abuse.
Clinical Code Mapping and Benefit Alignment
- Map diagnoses, procedures, drugs, and investigations to the correct clinical codes, benefits and diagnoses.
- Support accurate product and benefit mapping to improve automation and claims processing consistency.
- Work with data and system teams to highlight mapping gaps, rule errors and coding inconsistencies.
Clinical Reconciliation
- Reconcile claims against medical reports, prescriptions, invoices, treatment notes, discharge summaries and preauthorization records.
- Verify that services billed match the documented diagnosis, treatment provided and approved benefits.
- Flag mismatches, missing documents, unsupported charges and other reconciliation variances.
Documentation, Reporting, and Quality Assurance
- Document claim decisions clearly and accurately in the claims system.
- Prepare reports on deductions, savings, reconciliation findings, coding issues and claims trends whenever needed.
- Support audit, quality review, and continuous improvement activities within the claims function.
Stakeholder Coordination and Operational Support
- Liaise with providers, case managers, customer operations teams and other stakeholders to obtain clarifications and resolve claim queries.
- Provide timely feedback on pending documentation, disputed items and claim outcomes.
- Perform any other duties assigned by the supervisor.
EDUCATIONAL QUALIFICATIONS, KNOWLEDGE & EXPERIENCE:
- Degree or Diploma in Nursing, Clinical Medicine, Pharmacy, Medicine, or another related health qualification.
- Valid registration with the relevant professional body in Kenya.
- At least 2-4 years of experience in a busy clinical setting.
- A good understanding of medical insurance claims will be an added advantage.
- Experience in an Insurance company will be an added advantage
KEY SKILLS AND COMPETENCIES:
- Strong analytical and problem-solving skills
- Good clinical judgment and attention to detail
- Knowledge of claims adjudication, coding, and reconciliation processes
- Good oral and written communication skills
- Strong interpersonal and stakeholder management skills
- Ability to work under pressure and meet deadlines
- Good reporting and documentation skills
- High level of integrity, confidentiality, and professionalism
- Proficiency in claims systems and standard office tools
CarePay is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, family, gender identity, genetic information, marital status, race, religion or any other characteristic protected by applicable laws, regulations and ordinances.
