Risk & Claims Operations Specialist

Jackson Healthcare•Alpharetta, GA

About The Position

The Risk & Claims Operations Specialist supports the daily operations of the Risk Management and Claims Management functions across the Jackson Healthcare enterprise. This role is for someone who challenges the status quo, asking "why do we do it this way?" and actively seeking improvements. It operates through influence rather than authority, requiring the specialist to serve as a trusted partner to 22 distinct companies. Building relationships, communicating value, and driving process alignment are crucial, as there is no direct reporting line within these companies. The ability to earn trust, communicate clearly, and demonstrate consistent value is as important as technical skill. The ideal candidate is deadline-driven, process-oriented, and technologically savvy, possessing intellectual curiosity to challenge assumptions and initiative to pursue simpler, smarter solutions. Advanced Excel skills, a strong sense of ownership, and genuine openness to emerging technologies, including AI-powered tools like Microsoft Copilot and Claude, are essential. This role is designed for individuals excited by building better processes, working across a dynamic enterprise, and embracing innovation daily.

Requirements

High school diploma or equivalent required
5 - 7+ years of experience in process improvement, operations management, or cross-functional coordination
Demonstrated experience in process improvement, workflow optimization, or operational efficiency — with a track record of making things work better, not just differently
Experience managing high-volume, detail-intensive processes where accuracy and consistency are non-negotiable
Background in cross-functional collaboration — working across teams, departments, or companies to drive alignment and deliver results through influence
Experience in reporting, data integrity, or operations support in a matrixed or multi-entity environment strongly preferred
Advanced Microsoft Excel (pivot tables, VLOOKUPs, charts, and data analysis)
Proficiency with Microsoft 365 Suite (Outlook, Word, PowerPoint, Teams, SharePoint)
Comfort engaging with multiple platforms and systems
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
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

Nice To Haves

Bachelor's degree preferred, ideally in Risk Management, Operations, Business, or a related field
Experience in Risk Management, Healthcare Operations, or Credentialing
Experience with workflow mapping
Prior experience in Credentialing, Risk Management, or Claims

Responsibilities

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 preestablished 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
Take a leadership role in overseeing the integrity and performance of the automated claims verification process
Monitor exception queues and manage the review and confirmation of flagged claims before responses are issued
Maintain organized, audit-ready records and ensure process consistency across all verification activity
Identify opportunities to further strengthen and streamline the verification workflow
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
Identify opportunities to streamline coordination, reduce friction, and improve the overall process as workflows become better understood
Prepare monthly PowerPoint presentations summarizing Risk Review status and trends for company leadership
Build and maintain Excel-based tracking tools including pivot tables, charts, and VLOOKUPs
Analyze operational data to surface insights and support informed decision-making across the enterprise
Track contract reviews in Origami and other administrative functions as needed