Corporate Risk and Claims Specialist

Jackson Healthcare•Alpharetta, GA

1d•Hybrid

About The Position

Jackson Healthcare and its family of companies provide healthcare systems, hospitals, and medical facilities with skilled labor and technologies. Headquartered in metro Atlanta, the company employs over 2,600 associates and utilizes over 20,000 clinician providers across the U.S. The mission is to improve patient care and the lives of patients, clinicians, healthcare executives, communities, and associates. 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. This role is crucial for evaluating escalated provider files, confirming loss history and claims exceptions, and coordinating state-level PCF enrollments. The Specialist partners with company representatives, an external enrollment vendor, and insurance entities to ensure timely, accurate, and audit-ready outcomes.

Requirements

Bachelor's degree in Risk Management, Finance, Business Administration, or a related field required; equivalent combination of education and experience considered.
3 - 5 years of progressive experience in claims administration, insurance operations, or a related field required.
Experience with claims management systems and quality assurance processes required.
Demonstrated knowledge of property, casualty, or workers compensation claims processing required.
Strong organizational skills and ability to manage a claims workload independently.
Solid working knowledge of claims management systems, quality review tools, and insurance policy interpretation.
Ability to independently process standard claims and apply best practices in coverage evaluation and quality assurance.
Ability to troubleshoot routine claims issues and escalate complex matters appropriately.
Ability to handle problems of a moderate scope requiring a review of a variety of innovative factors.
Ability to apply Company policies and procedures to resolve a variety of issues; identify the most effective path to resolution.
Ability to exercise judgment within defined procedures for best results, balancing accuracy, timeliness, and compliance.
Effective communication skills to build productive internal and external working relationships.
Ability to clearly convey risk information, insurance status, and claims updates to business partners, carriers, and internal stakeholders.
Ability to collaborate with cross-functional partners including legal, finance, HR, and business units to advance risk objectives.
Has a 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.

Nice To Haves

Associate in Claims (AIC) designation preferred.
Experience with quality assurance or audit processes in an insurance or risk environment preferred.
Knowledge of regulatory requirements applicable to claims handling preferred.

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.
Support internal audit processes by preparing claims file samples, organizing documentation, and tracking audit findings.
Recommend process improvements based on quality review observations and recurring deficiency patterns.
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.
Coordinate 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.