Risk & Claims Operations Specialist

Key Responsibilities

• Risk Review Operations
• Manage the daily intake and completion of provider Risk Reviews within established deadlines.
• Evaluate escalated provider files using Microsoft Teams, SharePoint, VComm, MDStaff, and Outlook, applying pre-established guidelines and criteria to assess flagged exceptions.
• Investigate documentation thoroughly against defined standards, identifying and clearly articulating red flags in accordance with established protocols.
• Prepare concise, well-organized summary reports in Microsoft Word documenting findings and risk considerations.
• Assign the appropriate approval level to each provider file based on established criteria.
• Record all Risk Review outcomes in the Risk Management Information System (Origami).
• Communicate findings and approval status to company representatives across the Jackson Healthcare family in a clear, timely, and professional manner.
• Conduct annual audits comparing providers paid vs. Risk Reviews completed, analyzing year-over-year trends and reporting on gaps or process breakdowns.
• Claims Verification
• Take a leadership role in overseeing the integrity and performance of the automated claims verification process.
• Maintain organized, audit-ready records and ensure process consistency across all verification activity.
• Identify opportunities to further strengthen and streamline the verification workflow.
• Patient Compensation Fund (PCF) Enrollments
• Serve as the coordination hub between three Jackson companies, an external enrollment vendor, and the applicable insurance entities — ensuring enrollments are completed accurately, on time, and in compliance with each state's requirements.
• Coordinate enrollment activity across five states, navigating each state's distinct process and payment requirements.
• Serve as the primary point of contact and communication bridge between Jackson companies, the external enrollment vendor, and insurance entities.
• Track enrollment status, manage time-sensitive deadlines, and proactively communicate updates to all relevant stakeholders.
• Maintain accurate documentation throughout the enrollment lifecycle to support audit readiness and compliance.

Qualifications

• Education: Bachelor's degree preferred, ideally in Risk Management, Operations, Business, or a related field; high school diploma or equivalent required.
• Experience: 5 - 7+ years of experience in process improvement, operations management, or cross-functional coordination.
• Experience: Demonstrated experience in process improvement, workflow optimization, or operational efficiency — with a track record of making things work better, not just differently.
• Experience: Background in cross-functional collaboration — working across teams, departments, or companies to drive alignment and deliver results through influence.
• Experience: Prior experience in Credentialing, Risk Management, or Claims is helpful but secondary to operational and process credentials.

Skills & Abilities

• Technical: Advanced Microsoft Excel (required) — pivot tables, VLOOKUPs, charts, and data analysis.
• Software: Microsoft 365 Suite — Outlook, Word, PowerPoint, Teams, SharePoint.
• Emerging Technology: Genuine curiosity and openness to tools such as Microsoft Copilot and Claude; the ability to see and embrace these as productivity enablers rather than disruptions.
• Professional: Deadline-driven with a strong sense of ownership and accountability, process-oriented thinker who actively questions assumptions and pursues simpler, smarter solutions, comfortable with ambiguity and energized by change rather than unsettled by it, brings a fresh perspective — willing to ask "is this still the right way?" and explore alternatives, leads through influence — able to build trust, demonstrate value, and drive alignment across organizations without direct authority, skilled at navigating a multi-company environment with diverse stakeholders and competing priorities, meticulous attention to detail, particularly in time-sensitive and compliance-driven environments, excellent written and verbal communication skills, demonstrated ability to handle sensitive and confidential information with discretion, works effectively both independently and collaboratively.