Michael Ochara

Results-driven Licensed Clinical Officer and Medical Claims Analyst with over 6 years of progressive experience combining frontline clinical care with health insurance administration. Expertise spans medical claims adjudication, pre-authorization reviews for Social Health Authority (SHA) claims, utilization management, policy interpretation, and regulatory compliance in Kenya's dynamic healthcare and insurance sector. Proven ability to process high volumes of claims with clinical accuracy, maintain low rejection rates, support cost containment, and deliver exceptional member and provider service.

Strong analytical skills, clinical judgment, and attention to detail enable effective fraud risk identification, documentation improvement, and trend analysis. Seeking to leverage combined clinical and insurance expertise to contribute to efficient healthcare financing and quality patient outcomes in a reputable organization.

Care Manager / Medical Claims Analyst at MEDICAL ADMINISTRATOR KENYA LTD (MAKL) (2023-01 – Present)

• Reviewed and adjudicated an average of 25-40 medical claims daily, applying clinical judgment and policy guidelines to ensure appropriateness, medical necessity, and full compliance with benefit rules.
• Conducted thorough pre-authorization assessments for 15-20 cases per week, verifying documentation, diagnosis codes, and treatment plans to facilitate timely approvals while minimizing denials.
• Maintained consistently low claim rejection rates through rigorous first-level reviews, verification of supporting medical documentation, and proactive identification of gaps.
• Supported quality improvement initiatives by reviewing and enhancing documentation completeness prior to claim finalization, resulting in improved submission accuracy.
• Consistently achieved a 24-48-hour turnaround time for standard claims processing, contributing to high member and provider satisfaction.
• Handled 10-20 inbound and outbound calls daily, professionally resolving member inquiries, provider disputes, and benefit-related questions with empathy and accuracy.
• Assisted in the review of claims batches with a monthly financial exposure ranging from KES 5 million to 10 million, ensuring accurate risk assessment and appropriate approvals.
• Participated actively in internal audits, claims trend analysis, and risk identification exercises, providing actionable insights to reduce potential fraud, waste, and abuse.
• Collaborated with cross-functional teams to interpret evolving SHA and insurance policies, ensuring organizational adherence to regulatory standards.
• Key Achievements:
• Contributed to sustained low rejection rates through meticulous review processes.
• Enhanced team documentation standards, leading to smoother claims reconciliation.
• Developed strong proficiency in balancing clinical appropriateness with cost containment objectives.

Clinical Officer at MKUNGA MATERNITY & NURSING HOME (2022-02 – 2022-12)

• Delivered comprehensive outpatient care, managing 30-50 consultations daily for acute, chronic, and maternity-related cases, including history taking, physical examinations, diagnosis, and treatment planning.
• Interpreted diagnostic results (laboratory and imaging) accurately to inform evidence-based clinical decisions and patient management.
• Served as Quality Improvement Focal Person, playing a pivotal role in upgrading the facility from SafeCare Level 3 to Level 4 through implementation of standardized protocols, infection control measures, and documentation improvements.
• Maintained meticulous medical records and ensured full compliance with regulatory reporting requirements to county health authorities and other stakeholders.
• Provided patient-centered education on preventive health, medication adherence, and lifestyle modifications to improve health outcomes.
• Collaborated with multidisciplinary teams to coordinate patient referrals and ensure continuity of care.
• Key Achievements:
• Successfully drove quality improvement initiatives that elevated facility standards and patient safety metrics.
• Demonstrated strong leadership in a fast-paced maternity and nursing environment.

Clinical Officer at SAIKA NURSING HOME (2021-06 – 2022-01)

• Managed 25-35 patient consultations per shift, providing holistic care across general medicine, minor emergencies, and chronic disease management.
• Served as Clinical Officer-in-Charge, overseeing daily clinical operations, staff coordination, and smooth running of outpatient services.
• Ensured accurate, timely, and confidential patient documentation in line with professional and legal standards.
• Delivered targeted preventive health education sessions to patients, families, and facility staff on topics including hygiene, immunization, and disease prevention.
• Supported inventory management of essential medicines and medical supplies to maintain uninterrupted service delivery.
• Key Achievements:
• Effectively led clinical operations during the tenure, ensuring high standards of patient care and operational efficiency.

Clinical Medicine Internship at Outspan Hospital (2020 – 2021)

• Completed a comprehensive one-year internship program, rotating through key departments including Outpatient, Inpatient, Maternity, Paediatrics, and Surgical wards.
• Gained hands-on experience in patient assessment, minor surgical procedures, emergency response, and multidisciplinary team collaboration.
• Developed strong foundational skills in clinical documentation, ethical practice, and adherence to hospital protocols.

Diploma in Clinical Medicine & Surgery – Kenya Medical Training College (KMTC), Nyeri Campus (2016 – 2019)

Kenya Certificate of Primary Education (KCPE) – Central Primary School (2001 – 2008)

Kenya Certificate of Secondary Education (KCSE) – Kisumu Day High School (2009 – 2012)