Job Openings at Afia Concept Claims Settling Agency (ACS)

Role Purpose

• The Head of Finance is responsible for providing strategic financial leadership, ensuring sound financial management, regulatory compliance, financial planning, risk management, and business performance optimization across Afia Concept Claims Settling Agency (ACS). The role supports executive decision-making by delivering accurate financial insights, safeguarding company assets, maintaining financial sustainability, and driving operational efficiency.
• As a member of the senior leadership team, the Head of Finance will oversee all accounting, budgeting, payroll, taxation, procurement controls, audit processes, and financial reporting functions while supporting the company's growth strategy within the insurance claims management and healthcare administration sectors.

Key Accountabilities

Strategic Financial Leadership

• Develop and implement the company's financial strategy aligned with organizational goals.
• Provide financial guidance to the CEO and Board on strategic initiatives.
• Participate in business planning, expansion, and investment decisions.
• Lead financial feasibility studies and business case analyses.
• Monitor organizational financial performance and advise on corrective actions.
• Drive profitability, cost optimization, and sustainable growth initiatives.

Financial Planning & Analysis (FP&A)

• Lead annual budgeting and forecasting processes.
• Develop financial models to support business growth and strategic projects.
• Monitor budget utilization and departmental expenditure.
• Provide monthly, quarterly, and annual management accounts.
• Conduct variance analysis and recommend performance improvement measures.
• Develop key financial and operational performance indicators.

Financial Reporting & Accounting

• Ensure accurate and timely preparation of financial statements.
• Oversee general ledger management and account reconciliations.
• Maintain comprehensive accounting records and documentation.
• Ensure adherence to International Financial Reporting Standards (IFRS).
• Manage month-end and year-end financial closing processes.
• Oversee accounts payable, accounts receivable, and cash management functions.

Cash Flow Management

• Manage organizational cash flow and liquidity requirements.
• Develop cash forecasting models and working capital strategies.
• Oversee banking relationships and financial institutions.
• Monitor collections, vendor payments, and investment activities.
• Optimize cash utilization while maintaining adequate reserves.

Tax Management & Statutory Compliance

• Ensure compliance with all applicable tax regulations.
• Oversee timely filing and payment of PAYE, NSSF, SHIF/SHA, Housing Levy, VAT, Corporate Tax, and Withholding Tax.
• Coordinate tax audits and regulatory reviews.
• Advise management on tax planning opportunities and risks.

Internal Controls & Risk Management

• Develop and strengthen internal financial controls.
• Establish robust policies, procedures, and approval frameworks.
• Ensure safeguarding of company assets and funds.
• Identify financial risks and implement mitigation strategies.
• Monitor fraud prevention, detection, and reporting mechanisms.
• Support enterprise risk management initiatives.

Audit Coordination

• Lead preparation for internal and external audits.
• Coordinate responses to audit findings.
• Implement corrective actions arising from audit recommendations.
• Ensure continuous compliance with governance standards.

Payroll & Employee Benefits Administration

• Oversee payroll processing and reconciliation.
• Ensure statutory deductions and employee benefits are correctly administered.
• Review payroll controls and compensation-related reporting.
• Support HR with compensation budgeting and workforce planning.

Procurement & Cost Management Oversight

• Review procurement processes and expenditure controls.
• Ensure value-for-money principles are applied in purchasing decisions.
• Monitor contract costs and supplier performance.
• Approve procurement-related financial transactions within authorized limits.

Key Performance Indicators

• Budget accuracy and forecasting effectiveness
• Cash flow stability and liquidity management
• Timeliness and accuracy of financial reporting
• Profitability and cost management performance
• Audit outcomes and compliance ratings
• Tax compliance and statutory filing accuracy
• Reduction of financial risks and control breaches
• Collection efficiency and receivables management
• Finance team performance and development

Qualifications

• Bachelor's Degree in Finance, Accounting, Commerce, or Economics.
• Master's Degree in Finance, Accounting, Economics, MBA, or a related field is preferred.
• Professional qualification in at least one of CPA-K, ACCA, or CIMA.
• Additional qualifications such as Certified Internal Auditor (CIA), Certified Fraud Examiner (CFE), or Chartered Financial Analyst (CFA) will be an added advantage.

Experience

• Minimum 8–10 years of relevant finance experience.
• At least 5 years in a senior leadership or finance management role.
• Experience in the insurance sector, claims management, healthcare administration, or financial services.
• Proven experience managing annual budgets exceeding KES 100 Million is an added advantage.
• Demonstrated success in financial transformation and business growth initiatives.

go to method of application »

Role Purpose

• The Head of Business Development is responsible for driving business growth through the acquisition and retention of corporate clients, medical schemes, insurance partners, and strategic healthcare stakeholders. The role leads the development and execution of business development strategies that strengthen ACS's market position as a leading healthcare administration and managed care partner while driving revenue growth, client satisfaction, and long-term business sustainability.

Key Accountabilities

Business Growth & Market Expansion

• Develop and implement business development strategies aligned with the organization's growth objectives.
• Identify and pursue new business opportunities within the healthcare, insurance, and managed care sectors.
• Drive growth through acquisition of corporate clients, insurers, medical schemes, and strategic partnerships.
• Monitor market trends and competitor activities to identify opportunities and mitigate risks.
• Lead initiatives aimed at increasing market share and organizational visibility.

Client Acquisition & Retention

• Develop and maintain a robust sales pipeline.
• Generate new business through strategic prospecting and relationship management.
• Lead proposal development, presentations, negotiations, and contract discussions.
• Support client onboarding and implementation processes.
• Develop and execute client retention strategies to strengthen long-term partnerships.
• Conduct regular business reviews with key clients and stakeholders.

Insurance, Scheme & Corporate Partnerships

• Build and maintain relationships with insurers, medical schemes, brokers, and corporate organizations.
• Identify opportunities for strategic partnerships that enhance the organization's service offering.
• Collaborate with stakeholders to develop innovative healthcare administration solutions.
• Support negotiations and management of partnership agreements.
• Represent the organization in industry engagements and stakeholder forums.

Tender Management & Commercial Opportunities

• Identify and evaluate tender opportunities.
• Lead and coordinate responses to Requests for Proposals (RFPs), Expressions of Interest (EOIs), and tenders.
• Ensure timely and competitive submission of commercial proposals.
• Track tender outcomes and implement strategies to improve win rates.
• Coordinate cross-functional teams during bid preparation processes.

Account Management & Service Excellence

• Work closely with Client Success, Medical, Claims, and Provider Management teams to ensure excellent client service.
• Monitor client satisfaction and address escalated concerns.
• Support service improvement initiatives aimed at enhancing client experience.
• Ensure client commitments and contractual obligations are effectively managed.

Strategic Stakeholder Engagement

• Establish and maintain strong relationships with key decision-makers across the healthcare ecosystem.
• Engage with healthcare providers, insurers, regulators, and industry associations.
• Represent ACS at industry conferences, networking events, and business forums.
• Enhance the organization's reputation and market presence through strategic engagement.

Leadership & Team Management

• Provide leadership and direction to the Business Development team.
• Establish departmental objectives and performance targets.
• Monitor team performance and support staff development.
• Foster a high-performance and client-centric culture.
• Promote collaboration across departments to achieve business objectives.

Key Performance Indicators

• Revenue Growth: Drive sustainable revenue growth through acquisition of new clients and expansion of existing client accounts.
• New Business Acquisition: Secure new corporate clients, medical schemes, insurers, brokers, and strategic healthcare partners in line with organizational growth objectives.
• Client Retention: Maintain strong client relationships that contribute to contract renewals, client satisfaction, and long-term partnerships.
• Strategic Partnership Development: Establish and strengthen relationships with key stakeholders that enhance business opportunities and market presence.
• Tender & Proposal Success: Lead the development of competitive proposals and tender submissions that contribute to increased business wins.
• Market Growth & Expansion: Identify and capitalize on opportunities to expand the organization's presence across target markets and service segments.
• Key Account Development: Drive growth within existing accounts through relationship management, service enhancement, and identification of new business opportunities.

Qualifications

• Bachelor's Degree in Business Administration, Marketing, Commerce, Insurance, Healthcare Management, Public Relations, or a related field.
• Master's Degree in Business Administration (MBA), Strategic Management, Marketing, or a related field will be an added advantage.
• Professional qualifications in Sales, Marketing, Business Development, Customer Relationship Management, or Project Management will be an added advantage.

Experience

• Minimum of 8 years' progressive experience in business development, sales, account management, healthcare, insurance, managed care, or a related commercial environment.
• At least 3 years' experience in a leadership role.
• Demonstrated experience in client acquisition, contract negotiations, tender management, and strategic partnership development.
• Experience within a Third-Party Administration (TPA), health insurance, medical scheme administration, healthcare services, or managed care environment is highly desirable.
• Strong understanding of healthcare financing, medical insurance, managed care, and healthcare administration models.

go to method of application »

Role Purpose

• The Senior Manager - ICT is responsible for providing strategic and operational leadership in the development, implementation and management of ACS's information and communication technology infrastructure, systems and digital solutions.
• The role ensures the availability, security, reliability and scalability of technology platforms supporting healthcare claims administration, pre-authorisation, member and provider services, data management and business operations.
• The Senior Manager - ICT will drive digital transformation, strengthen information security and data protection, improve systems integration and automation, and ensure that technology investments support organisational strategy, operational efficiency, service quality and business growth.

Key Accountabilities

ICT Strategy and Digital Transformation

• Develop and implement an ICT strategy aligned with ACS's business objectives and growth priorities.
• Provide strategic advice to the COO and senior management on technology investments, emerging technologies and digital transformation opportunities.
• Identify opportunities to automate manual processes, improve workflows and enhance service delivery through technology.
• Develop and maintain an ICT roadmap covering infrastructure, applications, systems integration, cybersecurity and business continuity.
• Evaluate and recommend appropriate technology solutions that support business scalability and operational efficiency.

Systems Development and Business Applications

• Oversee the implementation, maintenance and optimisation of business applications supporting claims processing, pre-authorisation, member management, provider administration and reporting.
• Ensure effective integration between business systems to improve information flow, accuracy and operational visibility.
• Drive the automation of manual processes, including claims tracking, reconciliations, reporting and workflow management.
• Oversee the management, availability and continuous improvement of member and provider portals and other digital service channels.
• Work with business stakeholders and technology vendors to define system requirements, manage implementations and resolve application issues.
• Ensure systems are fit for purpose, user-friendly, scalable and aligned with business needs.

Infrastructure and Service Delivery

• Oversee the management and maintenance of ICT infrastructure, including networks, servers, cloud services, end-user devices, communication systems and business applications.
• Ensure the availability, performance, reliability and security of ICT systems.
• Establish ICT service standards, incident management procedures and service-level agreements.
• Oversee the ICT helpdesk, ensuring timely resolution of user requests, technical incidents and system failures.
• Manage technology assets, licences, configurations and lifecycle replacements.
• Ensure adequate ICT resources, tools and support arrangements are available to employees.

Cybersecurity, Data Protection and Information Governance

• Develop and implement ICT security policies, standards and controls to protect ACS's information assets.
• Establish appropriate access controls, user authentication, privileged access management and system monitoring.
• Protect confidential member, provider, payer and scheme information against unauthorised access, loss, disclosure or misuse.
• Ensure ICT practices comply with applicable data protection legislation, regulatory requirements, contractual obligations and internal policies.
• Conduct periodic reviews of system vulnerabilities, security risks and access rights.
• Coordinate cybersecurity awareness, incident response and investigation of technology-related security breaches.
• Maintain appropriate audit trails, system logs and information retention controls.

Business Continuity and Disaster Recovery

• Develop, implement and periodically test ICT business continuity and disaster recovery plans.
• Ensure regular backups, secure backup storage and tested data restoration procedures.
• Establish system recovery priorities, recovery time objectives and recovery point objectives in consultation with business stakeholders.
• Coordinate responses to system outages, cyber incidents and other technology disruptions.
• Ensure critical business systems can be restored within agreed recovery timelines.
• Document incidents, corrective actions and lessons learned to strengthen operational resilience.

Data Management, Reporting and Analytics

• Establish appropriate standards for data integrity, data quality, accessibility and security.
• Support the development of reliable management dashboards and operational reports.
• Work with business teams to improve data availability for claims performance monitoring, service turnaround analysis, utilisation reporting and operational decision-making.
• Promote appropriate use of business intelligence, analytics and automation tools.
• Ensure data interfaces, reporting processes and system outputs are accurate, consistent and reliable.

Vendor and Contract Management

• Manage relationships with ICT service providers, software vendors, telecommunications providers and technology partners.
• Define technical requirements, service expectations and performance standards for external providers.
• Monitor vendor performance against contractual obligations and agreed service levels.
• Evaluate technology proposals and conduct technical assessments to support procurement decisions.
• Negotiate service arrangements and recommend cost-effective solutions.
• Ensure appropriate due diligence, confidentiality provisions, security requirements and exit arrangements are in place for technology vendors.

ICT Budgeting and Resource Management

• Develop and manage the annual ICT budget in consultation with the COO and Finance function.
• Monitor expenditure, technology costs and budget utilisation.
• Prepare business cases for ICT investments, demonstrating expected benefits, costs, risks and value for money.
• Optimise technology expenditure while maintaining appropriate service quality, security and resilience.
• Oversee ICT asset management, licence renewals and resource allocation.
• Lead, coach and develop ICT staff to build technical capability, accountability and service orientation.

Risk Management, Audit and Compliance

• Maintain an ICT risk register and implement appropriate mitigation measures.
• Coordinate ICT audits, vulnerability assessments, compliance reviews and closure of audit findings.
• Ensure technology changes are properly assessed, tested, approved and documented before implementation.
• Establish change management, configuration management and system documentation standards.
• Report significant ICT risks, incidents, service disruptions and remediation progress to the COO.
• Promote a culture of accountability, continuous improvement and responsible technology use.

Qualifications

• Bachelor's degree in Information Technology, Computer Science, Information Systems, Software Engineering or a related field from a recognised institution.
• A relevant master's degree in Information Technology, Information Systems, Cybersecurity, Business Information Systems or Technology Management will be an added advantage.
• Professional certification in one or more relevant areas, such as ITIL, COBIT, CISSP, CISM, CISA, cloud technologies or project management, will be an advantage.
• Relevant training in information security, data protection, enterprise systems or IT service management will be desirable.

Experience

• At least eight (8) years of relevant ICT experience, including a minimum of three (3) years in a management or leadership role.
• Demonstrable experience managing ICT infrastructure, enterprise applications, cybersecurity, systems integration and technology service delivery.
• Experience implementing or managing business systems in healthcare, insurance, health financing, claims administration or another regulated environment will be an advantage.
• Proven experience leading ICT projects, managing technology vendors and budgets, and delivering systems improvements.
• Experience in cloud services, business continuity, disaster recovery, data management and information security.
• Demonstrated ability to translate business requirements into practical, scalable technology solutions.

go to method of application »

Role Purpose

• The Care Manager is a clinically trained professional at the heart of ACS's medical operations function. The role carries three interconnected responsibilities: adjudicating pre-authorizations with speed and clinical accuracy, negotiating medical costs with healthcare providers during active admissions and service delivery, and providing sound clinical guidance to members navigating the healthcare system.
• A particularly critical aspect of this role is the ability to step down care — identifying situations where a member can receive equivalent quality of treatment at a more cost-effective facility or care setting, and facilitating that transition in a way that is clinically safe, member-centred, and clearly communicated. The Care Manager must balance advocacy for the member's health outcomes with stewardship of scheme sustainability.
• The ideal candidate is a clinically confident, commercially aware healthcare professional — typically a registered nurse or clinician with managed care experience — who can make sound, defensible clinical decisions under time pressure while maintaining strong relationships with providers, members, and internal teams.

Key Accountabilities

Care Coordination & Case Management

• Coordinate and manage care plans for assigned members.
• Conduct clinical assessments and evaluate members' healthcare needs.
• Monitor admissions, ongoing treatment, referrals, and discharge processes.
• Facilitate continuity of care across healthcare providers and service points.
• Ensure timely escalation of critical and emergency cases.

Utilization Management

• Review treatment plans to ensure appropriateness, quality, and cost-effectiveness.
• Facilitate pre-authorizations and care approvals in accordance with clinical guidelines.
• Monitor healthcare utilization and identify opportunities for cost containment.
• Support interventions aimed at reducing unnecessary admissions and readmissions.

Provider & Stakeholder Engagement

• Liaise with healthcare providers to coordinate member care and treatment plans.
• Collaborate with internal teams to ensure seamless service delivery.
• Participate in provider engagements, case reviews, and clinical discussions.
• Foster positive relationships with members, providers, and other stakeholders.

Chronic Disease & Wellness Management

• Monitor high-cost, chronic, and complex medical cases.
• Support disease management and wellness initiatives.
• Promote preventive healthcare and member education programs.
• Guide members on available healthcare resources and treatment options.

Member Advocacy & Experience

• Act as an advocate for members throughout their healthcare journey.
• Provide guidance on benefit utilization and access to care.
• Address member concerns and facilitate timely resolution of service issues.
• Support initiatives aimed at improving member satisfaction and outcomes.

Clinical Quality & Compliance

• Ensure adherence to clinical protocols, policies, and regulatory requirements.
• Participate in clinical audits, quality reviews, and risk management activities.
• Monitor quality indicators and recommend improvement initiatives.
• Support implementation of evidence-based clinical practices.

Reporting & Documentation

• Maintain accurate and up-to-date clinical records and case documentation.
• Prepare care management, utilization, and case review reports.
• Track and report on key care management metrics and outcomes.
• Ensure confidentiality and proper management of member information.

Key Performance Indicators

• Member Care Coordination
• Quality of Clinical Outcomes
• Case Management Effectiveness
• Timeliness of Pre-Authorizations
• Member Satisfaction
• Care Plan Compliance
• Hospitalization and Readmission Management
• Utilization Management Effectiveness

Qualifications

• Bachelor's Degree or Diploma in Nursing, Clinical Medicine, Medicine, Pharmacy or a related healthcare field.
• Valid professional registration and licensing where applicable.

Added Advantage

• Professional qualification in AIIK, ACII, or Certificate in Insurance.
• Formal training in customer experience or call centre operations.
• Knowledge of medical scheme operations, SLAs, and healthcare provider management.
• Understanding of ISO Quality Standards and Data Protection Act compliance.

Experience

• Minimum of 2 years' experience in case management, utilization management, clinical care, managed care, medical insurance, or healthcare administration.
• Experience in a medical insurance, TPA, healthcare management, or managed care environment is preferred.
• Knowledge of healthcare benefits, pre-authorizations, and clinical protocols.

go to method of application »

Role Purpose

• The Call Centre Executive serves as the first point of contact for members, delivering professional customer service while addressing general clinical enquiries. Leveraging a clinical background, the role provides accurate guidance, resolves medical queries at first contact where appropriate, and escalates complex cases when necessary. The role combines strong customer service skills with sound clinical judgement to enhance member experience, improve response times, and support efficient healthcare service delivery.

Key Accountabilities

Call Centre Operations

• Handle inbound and outbound calls, emails, and messages from members, providers, clients, and other stakeholders in a professional and timely manner.
• Provide accurate information on scheme benefits, exclusions, processes, and services, resolving enquiries at first contact wherever possible.
• Escalate complex or unresolved queries to the appropriate teams and follow through to timely resolution.
• Accurately record all customer interactions, enquiries, resolutions, and escalations in the call centre system.
• Achieve agreed service standards and key performance indicators, including response times, first contact resolution, call quality, and customer satisfaction.

Clinical Support & Medical Query Resolution (where applicable)

• Assess and triage medical enquiries, applying clinical judgement to determine the appropriate course of action.
• Resolve routine clinical queries at first contact and escalate complex cases to the appropriate clinical team.
• Advise members on appropriate healthcare providers, levels of care, and available scheme benefits.
• Identify members requiring urgent or emergency care and facilitate prompt referral or escalation.
• Adjudicate outpatient pre-authorizations within the approved authority limits and escalate cases outside the approval matrix.

Member Experience & Relationship Management

• Deliver a professional, empathetic, and member-centered experience across all interactions.
• Build member trust by providing accurate information, clinical guidance, and responsive support.
• Follow up on unresolved queries, complex cases, and recent admissions to ensure continuity of care and service.
• Capture member feedback and escalate recurring issues or complaints to support service improvement.
• Promote a positive member experience by ensuring timely communication and effective resolution of enquiries.

Documentation & Compliance

• Maintain accurate and complete records of all clinical advice, member interactions, and related activities.
• Ensure compliance with data privacy, confidentiality, and health information protection requirements.
• Adhere to internal policies, clinical protocols, escalation procedures, and quality standards.
• Participate in call audits, quality assurance reviews, and performance improvement initiatives.
• Support continuous improvement by implementing feedback and maintaining professional standards.

Team Collaboration & Knowledge Sharing

• Collaborate with internal teams to ensure seamless coordination of member care and service delivery.
• Share insights from member enquiries to support process improvements, training, and knowledge resources.
• Support the onboarding and development of team members by sharing clinical knowledge and best practices.
• Participate in team meetings, training sessions, and clinical updates to maintain professional competence.
• Contribute to continuous improvement initiatives that enhance service quality and operational efficiency.

Reporting & Continuous Improvement

• Track and report on medical query volumes, first-contact resolution rates, and escalation patterns.
• Identify trends in member queries that may indicate gaps in benefit communication, scheme design, or provider service quality.

Key Performance Indicators

• Customer Satisfaction (CSAT)
• First Contact Resolution (FCR)
• Call Quality Audit Score
• Clinical Query Accuracy
• Pre-authorization Decision Accuracy
• Service Level Compliance
• Call Documentation Accuracy
• Data Privacy and Regulatory Compliance

Qualifications

• Diploma or Bachelor's degree in Nursing, Clinical Medicine, Public Health, or Healthcare Management or equivalent.

Added Advantage

• Professional qualification in AIIK, ACII, or Certificate in Insurance.
• Formal training in customer experience or call centre operations.
• Knowledge of medical scheme operations, SLAs, and healthcare provider management.
• Understanding of ISO Quality Standards and Data Protection Act compliance.

Experience

• Minimum of 2 years' relevant experience in medical insurance administration, provider relations, or healthcare scheme management, preferably within an insurance company, brokerage firm, or medical service provider network.
• Experience in a customer-facing, call centre, telehealth, or health insurance environment is an added advantage.

go to method of application »

Role Purpose

• The Client Success Executive is the day-to-day point of contact for assigned clients, responsible for building strong, professional relationships and ensuring every client request, service issue, and complaint is coordinated across ACS's Claims, Medical, Care Management, Provider Relations, and Finance teams and resolved on time.
• The role supports client onboarding, monitors service delivery against agreed standards, and gathers client feedback to drive continuous improvement, client satisfaction, and long-term retention.

Key Accountabilities

Client Relationship Management

• Develop and maintain positive and professional relationships with assigned clients.
• Serve as a primary contact for day-to-day client enquiries and service-related matters.
• Build a thorough understanding of client requirements, expectations, and operational needs.
• Conduct regular client engagement and follow-up activities to strengthen relationships.
• Ensure clients receive timely communication and support regarding their requests.
• Foster client confidence through responsive and solution-oriented service.

Client Support & Service Delivery

• Coordinate client requests and ensure prompt action by the relevant departments.
• Monitor service delivery to ensure adherence to agreed service standards and commitments.
• Follow up on outstanding issues to ensure timely resolution.
• Support the implementation of client-specific requirements and initiatives.
• Ensure accurate communication of client needs to internal stakeholders.
• Track service issues and ensure closure within agreed timelines.

Client Onboarding & Account Management

• Support onboarding activities for new clients and members.
• Facilitate collection and maintenance of client information and documentation.
• Assist clients in understanding available services, processes, and support channels.
• Coordinate client account updates, benefit changes, and service notifications.
• Support implementation of new programs, products, and service offerings for clients.

Stakeholder Coordination

• Work closely with Claims, Medical, Care Management, Provider Relations, Finance, Operations, and Customer Experience teams to address client needs.
• Coordinate internal follow-up on client concerns and service matters.
• Facilitate communication between clients and internal stakeholders.
• Escalate complex issues through appropriate channels and monitor progress until resolution.

Complaint & Issue Resolution

• Receive, document, and track client complaints and service concerns.
• Investigate service issues and liaise with relevant departments to obtain resolutions.
• Provide timely updates to clients on the status of ongoing issues.
• Ensure complaints are managed professionally and resolved satisfactorily.
• Identify recurring service issues and recommend corrective actions.
• Maintain records of client feedback, complaints, and resolutions.

Client Engagement & Retention

• Support activities aimed at enhancing client satisfaction and loyalty.
• Participate in client meetings, service reviews, and engagement sessions.
• Gather and document client feedback for continuous improvement purposes.
• Promote positive client experiences through proactive support and communication.

Reporting & Administration

• Maintain accurate records of client interactions, requests, and service activities.
• Prepare routine client service reports and status updates.
• Track open action items and ensure timely follow-up.
• Maintain client files, correspondence, and related documentation.
• Support preparation of presentations, meeting minutes, and engagement materials.
• Ensure proper management of client information and records.

Compliance & Quality Assurance

• Adhere to company policies, procedures, and service standards.
• Ensure confidentiality and proper handling of client information.
• Maintain compliance with contractual and regulatory requirements.
• Contribute to a culture of professionalism, accountability, and customer excellence.

Key Performance Indicators

• Client Satisfaction
• Client Query Resolution
• Complaint Resolution
• Service Delivery Coordination
• Client Retention
• Stakeholder Relationship Management
• Follow-up and Action Closure

Qualifications

• Bachelor's Degree in Business Administration, Marketing, Public Relations, Communications, Insurance, Healthcare Management, or a related field.
• Proficiency in Microsoft Office applications.

Experience

• Minimum of 2 years' experience in client service, account management, customer experience, healthcare administration, insurance, or a related field.
• Experience within healthcare, insurance, managed care, or customer-facing environments will be an added advantage.

go to method of application »

Role Purpose

• The Provider Reconciliation Officer is responsible for ensuring accurate reconciliation of healthcare providers' accounts by validating claims, invoices, payments, recoveries, credit notes, and provider statements. The role plays a critical part in maintaining financial accuracy, supporting timely provider settlements, minimizing disputes, and fostering positive provider relationships.
• Within a Third-Party Administration (TPA) environment, the incumbent serves as a key liaison between healthcare providers, claims teams, medical teams, finance teams, and clients to ensure that provider accounts accurately reflect services rendered, approved claims, payments made, and outstanding balances. The role requires strong analytical skills, attention to detail, and a thorough understanding of healthcare claims processing and provider payment cycles.

Key Accountabilities

Provider Account Reconciliation

• Perform regular reconciliation of provider statements against adjudicated claims and payment records.
• Verify the accuracy of provider invoices, statements, remittances, and account balances.
• Match approved claims against payments made to healthcare providers.
• Review provider accounts to identify discrepancies, overpayments, underpayments, duplicate payments, and unallocated transactions.
• Investigate and resolve unidentified or unmatched transactions.
• Maintain accurate reconciliation schedules and supporting documentation.

Claims and Payment Verification

• Validate claims included in provider invoices prior to payment processing.
• Reconcile approved claims against contractual payment schedules and approved tariffs.
• Verify deductions, recoveries, reversals, and adjustments applied to provider accounts.
• Review rejected and partially settled claims and ensure proper documentation.
• Ensure all payment records are accurately reflected in reconciliation reports.
• Collaborate with Claims and Finance teams to address payment variances.

Provider Query and Dispute Resolution

• Respond promptly to provider enquiries relating to invoices, payments, deductions, recoveries, and account balances.
• Investigate provider disputes and reconciliation exceptions.
• Liaise with relevant internal departments to obtain supporting documentation and resolutions.
• Maintain records of provider disputes and resolution actions.
• Follow up on open reconciliation issues until closure.
• Ensure timely communication with providers regarding outstanding matters.

Financial Control and Risk Management

• Identify financial discrepancies and escalate material risks appropriately.
• Monitor ageing balances and unresolved reconciliation items.
• Support recovery of overpayments and identification of duplicate claims.
• Ensure compliance with reconciliation controls and financial procedures.
• Assist in prevention and detection of billing irregularities and fraudulent claims.
• Contribute to initiatives aimed at improving payment accuracy and financial controls.

Provider Relationship Management

• Maintain professional working relationships with healthcare providers.
• Participate in provider engagement meetings where reconciliation issues are discussed.
• Support initiatives aimed at improving provider satisfaction and payment transparency.
• Promote effective communication between providers and internal stakeholders.
• Facilitate resolution of provider concerns through collaborative engagement.

Reporting and Documentation

• Prepare daily, weekly, and monthly reconciliation reports.
• Generate exception reports highlighting unresolved discrepancies.
• Maintain comprehensive reconciliation records and supporting documentation.
• Monitor reconciliation trends and recurring issues.
• Provide reconciliation updates to management as required.
• Support month-end and year-end financial reporting processes.

Process Improvement

• Identify gaps and inefficiencies within reconciliation processes.
• Recommend improvements to enhance reconciliation accuracy and efficiency.
• Participate in process improvement projects and system enhancement initiatives.
• Support implementation of new controls, procedures, and reconciliation tools.
• Contribute to continuous improvement of provider settlement processes.

Compliance and Governance

• Ensure compliance with organizational policies and procedures.
• Adhere to contractual agreements with healthcare providers.
• Maintain confidentiality of provider, client, and member information.
• Support audit exercises by providing reconciliation documentation and reports.
• Ensure compliance with regulatory and industry requirements.
• Promote adherence to ethical and professional standards.

Key Performance Indicators

• Provider Reconciliation Accuracy
• Timeliness of Reconciliation Completion
• Provider Query Resolution
• Outstanding Reconciliation Item Resolution
• Claims and Payment Matching Accuracy
• Provider Dispute Resolution
• Compliance with Reconciliation Procedures
• Accuracy and Timeliness of Reconciliation Reports

Qualifications

• Bachelor's Degree in Accounting, Finance, Business Administration, Economics, Insurance, Health Records, Healthcare Management, or a related field.
• Proficiency in Microsoft Excel and reconciliation systems.

Experience

• Minimum of 2 years' experience in healthcare finance, claims management, provider reconciliation, medical insurance, managed care, or a related field.
• Experience working within a TPA, health insurer, managed care organization, or healthcare administration environment is preferred.

go to method of application »

Role Purpose

• The Medical Claims Analyst role is responsible for the accurate, timely, and compliant adjudication of medical claims submitted by healthcare providers on behalf of scheme members. It requires someone who can interpret medical documentation, apply benefit rules, identify anomalies, and contribute to the continuous improvement of ACS's claims processes. The analyst works closely with the Care Management, Provider Relations, Finance, and Client Success teams to ensure claims are processed fairly, efficiently, and in accordance with contracted terms and regulatory requirements.

Key Accountabilities

Claims Adjudication, Medical Review & Utilization Management

• Review, assess, and adjudicate inpatient, outpatient, dental, optical, pharmacy, and reimbursement claims in accordance with scheme benefits, policy terms, exclusions, limitations, and contractual provider agreements.
• Verify member eligibility, active cover status, benefit availability, and service validity before processing claims.
• Review clinical documentation including medical notes, diagnoses, ICD-10/ICD-11 codes, procedure codes, laboratory and radiology reports, discharge summaries, prescriptions, operative notes, and itemized invoices to validate claims accuracy.
• Assess medical necessity and appropriateness of services, procedures, investigations, medications, admissions, and length of stay against clinical guidelines and ACS utilization management protocols.
• Review claims against approved pre-authorizations to confirm alignment with approved treatment plans, authorized services, and applicable limits, escalating variances where required.

Claims Quality Assurance, Accuracy & Cost Management

• Review provider bills to identify overcharging, duplicate billing, incorrect tariffs, unsupported services, unbundled charges, and incorrect benefit application.
• Confirm that billed services are supported by medical documentation and match the diagnosis and treatment provided.
• Apply agreed provider tariffs, negotiated rates, package rates, discounts, and payment arrangements when processing claims.
• Identify unnecessary costs and apply appropriate claims controls to support cost management.
• Identify savings opportunities through claims review, billing corrections, tariff application, and utilization management.

Fraud, Waste & Abuse Detection

• Identify possible fraud, waste, and abuse, including fake claims, inflated bills, duplicate claims, unnecessary services, and billing for services not provided.
• Review provider and member claim patterns to identify unusual or suspicious activities.
• Escalate suspected fraud, waste, and abuse cases in line with ACS escalation procedures.
• Support investigations by providing claim reviews, documentation, and utilization reports.
• Support improvement of claims rules and system controls to prevent fraud and inappropriate payments.

Provider Management, Stakeholder Engagement & Query Resolution

• Respond to provider queries on claim status, approvals, rejections, payment issues, and documentation requirements within agreed timelines.
• Confirm provider claims are billed according to agreed tariffs, packages, discounts, and contractual terms.
• Work with the Provider Relations team to resolve billing errors, tariff issues, and recurring provider concerns.
• Work with Care Management, Finance, and Client Success teams to resolve claims-related issues and improve service delivery.
• Provide feedback on provider billing trends and areas requiring improvement.

Claims Reporting, Analytics & System Management

• Track and report on savings achieved through claims edits, overbilling recoveries, and application of contracted rates versus billed charges.
• Support scheme reporting, reconciliation, and claims performance reviews.
• Ensure accurate entry and maintenance of claims information in the claims management system.
• Participate in testing system improvements, automated claims rules, and workflow enhancements.

Key Performance Indicators

• Care Plan Management and Member Satisfaction
• Pre-Authorization Turnaround Time
• Clinical Case Review Accuracy
• Hospital Admission Management
• Discharge Planning Effectiveness
• Chronic Disease Management Outcomes
• Escalation and Critical Case Management
• Healthcare Utilization Management
• Clinical Documentation Quality
• Provider Engagement and Collaboration
• Compliance with Clinical Protocols
• Case Resolution Timeliness
• Reporting Accuracy and Timeliness
• Data Protection and Confidentiality Compliance
• Cost Containment and Care Optimization

Qualifications

• Diploma or Bachelor's Degree in Nursing, Clinical Medicine, Health Records & Information Management, Public Health, or a related health sciences field.

Added Advantage

• Professional qualifications in AIIK, ACII, or Certificate in Insurance.
• Familiarity with managed care concepts, utilization review, and medical tariff structures applicable in the Kenyan market.
• Experience working with a claims management system, TPA platform, or health insurance adjudication software.
• Understanding of the Insurance Act (Cap. 487), IRA guidelines, and the Kenya Data Protection Act, 2019.