Claims Analyst, Retail Health

Role overview

This position supports risk control by checking whether applicants qualify for medical cover, reviewing how schemes are performing, suggesting suitable renewal terms, and handling administration for members already covered under the company’s healthcare plans while meeting service standards.

Core duties

• Examine, verify, record, and process outpatient and inpatient claims in line with the claims manual and the required turnaround times.
• Scan, barcode, and batch incoming claims without delay.
• Handle reimbursement processing within the agreed timelines.
• Carry out quality checks before claim batches are approved for payment runs.
• Inform brokers and clients about claims that are put on hold or declined, within the expected timeframes.
• Follow up and manage claims that have been pended or declined.
• Work with agents, brokers, and service providers on claim-related issues.
• Ensure all claim records are filed and archived correctly in the relevant systems.
• Keep claims output at the required target levels.
• Prepare and issue a daily status report for health claims.
• Store all related correspondence in the Medware system.
• Track and process NHIF enhanced benefits to support cost containment.
• Log and monitor roaming and counter-guarantee claims.
• Respond to customer questions by phone, letter, email, and in-person visits.
• Maintain high standards of professionalism, discipline, and confidentiality, especially regarding patients’ medical information.
• Comply with governance obligations relating to KYC, AML, and data protection under the relevant laws.

Qualifications and experience

A bachelor’s degree in Insurance or a business-related field is required. The role also expects progress toward a Diploma in Insurance (ACII or AIIK), with at least 3 papers completed or an equivalent level. Applicants should have at least 1 year of experience handling medical claims in an insurance or hospital environment.

Knowledge and competencies

• Solid grasp of insurance operations and core insurance concepts.
• Awareness of applicable insurance regulatory requirements.
• Working knowledge of claims handling procedures.
• Strong organization and stakeholder management abilities.

Application notes

Applicants who meet the criteria should send their application and updated CV by 12 July 2026, and include the job title in the email subject line. The employer is an equal opportunity organization and welcomes diversity. Shortlisted candidates only will be contacted. Any personal information gathered during recruitment will be used for hiring purposes and handled in line with the organization’s privacy statement.