Corporate Risk and Claims Specialist

About the role

The Corporate Risk and Claims Specialist is an Individual Contributor responsible for the daily execution of provider Risk Reviews, malpractice Claims Verification, and Claim administration across the Jackson Healthcare family of companies.

Responsibilities

• Manage end-to-end claims intake and processing, including claim logging, coverage verification, adjuster assignment, and documentation collection.
• Evaluate claim submissions for coverage applicability, completeness, and compliance with policy requirements; escalate complex coverage questions appropriately.
• Monitor open claims for timely resolution; coordinate with adjusters, carriers, and internal stakeholders to advance claim progress.
• Maintain accurate claims records in the claims management system; ensure data integrity and timely updates.
• Conduct quality reviews of claims files to verify accuracy, completeness, and compliance with internal standards and regulatory requirements.
• Apply quality scoring frameworks to evaluate adjuster performance and claims handling outcomes; summarize findings for supervisor review.
• Serve as a point of contact for claimants, internal departments, adjusters, and carriers on routine claims matters.
• Communicate claim status, coverage determinations, and resolution timelines clearly and professionally.
• Cook documentation exchanges between internal and external parties to support timely claims resolution.
• Prepare claims status summaries and correspondence as required by the claims team or business partners.
• Identify gaps in claims processes and recommend workflow improvements to the Senior Corporate Risk and Claims Specialist.
• Produce routine claims reports including volume, cycle time, open claim aging, and quality metrics.
• Support special projects and ad hoc analyses as assigned by senior team members.

Qualifications

• Required: Bachelor's degree in Risk Management, Finance, Business Administration, or a related field; 3 - 5 years of progressive experience in claims administration, insurance operations, or a related field; experience with claims management systems and quality assurance processes; demonstrated knowledge of property, casualty, or workers compensation claims processing; strong organizational skills and ability to manage a claims workload independently.
• PREFERRED: Associate in Claims (AIC) designation; experience with quality assurance or audit processes in an insurance or risk environment; knowledge of regulatory requirements applicable to claims handling.

Knowledge, Skills, and Abilities

• Technical Skills: Solid working knowledge of claims management systems, quality review tools, and insurance policy interpretation; independently processes standard claims and applies best practices in coverage evaluation and quality assurance; troubleshoots routine claims issues and escalates complex matters appropriately.
• Problem-Solving & Innovation: Handles problems of a moderate scope requiring a review of a variety of innovative factors; applies Company policies and procedures to resolve a variety of issues; identifies the most effective path to resolution.
• Quality & Decision-Making: Optimal results are submitted with fewer corrections; manages work to identify areas of improvement; exercises judgment within defined procedures for best results, balancing accuracy, timeliness, and compliance.
• Communication: Effective communication builds productive internal and external working relationships; clearly conveys risk information, insurance status, and claims updates to business partners, carriers, and internal stakeholders.
• Teamwork & Mentorship: Receives little instruction on daily work and new assignments; engages with the team; collaborates with cross-functional partners including legal, finance, HR, and business units to advance risk objectives.
• Professional Development: Broad range of expertise and understanding of the Company's objectives; pursues industry certifications, professional development programs, and emerging risk management knowledge to advance expertise.