Company Overview

Afia Concept Claims Settling Agency (ACS) is a forward-thinking healthcare consulting firm operating in East Africa, with headquarters in Nairobi, Kenya. Established to bridge the gap between healthcare infrastructure and accessible, high-quality services, ACS offers end-to-end solutions in healthcare facility design, health financing advisory, digital health, and operational management.

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.

• 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.
• 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.
• 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.
• 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.
• 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.
• 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.

• Customer service
• Clinical judgement
• Call centre operations
• Medical query resolution
• Data privacy
• Confidentiality
• Health information protection
• Team collaboration
• Knowledge sharing

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