Risk, Claims, & Insurance Specialist at South County Hospital – Wakefield, Rhode Island

Position Summary: Serves as the organization’s subject matter expert in claims and insurance program operations, managing claims, litigation, and risk financing, including the self-insured trust and all commercial insurance coverages.

Coordinates with legal counsel, insurers, and brokers to ensure timely, accurate claims management, regulatory compliance, and insurance renewals. Partners with the Director of Risk Management/Patient Safety to support event reporting and investigations, translating claims and litigation experience into insights that drive patient safety and risk mitigation. With regard to claims and litigation, takes actions under the direction of the General Counsel, external legal counsel, and Claims/Risk Committee.

Provides cross-functional support, including coverage of Director and Risk Analyst responsibilities as appropriate, to ensure continuity of operations and alignment of risk, claims, and patient safety efforts.

Essential Responsibilities

Claims & Litigation Management

• Manage all potentially compensable events, claims, and litigation across professional and general liability and other applicable coverage.
• Maintain complete, accurate, and organized claims and litigation files within the RLDatix Claims module
• Coordinate claims intake, investigation documentation, and case file development
• Under supervision of General Counsel, serve as liaison with insurance carriers, claims representatives, defense counsel, and internal stakeholders
• Support and coordinate legal processes, including discovery, document production, interrogatories, and information requests
• Coordinate depositions, testimony, and meetings between staff and legal counsel
• Manage subpoenas and legal requests, ensuring appropriate handling and coordination
• Participate in early resolution strategies and settlement preparation pursuant to the direction of General Counsel and external legal counsel.
• Maintain awareness of claim exposure, reserves (as applicable), and case status
• Chair the organization’s Claims Committee and coordinate case review activities
• Ensure timely and accurate regulatory reporting of claims and litigation[AP1] (e.g., Rhode Island DBR requirements)

Insurance Program Oversight

• Direct day-to-day operations of the organization’s insurance program, including the self-insured trust (Circle Protection Plan) and all commercial lines of coverage
• Serve as primary liaison with the organization’s insurance broker
• Lead all insurance renewal activities, ensuring accurate, timely, and complete submission of applications and required documentation
• Coordinate data collection and underwriting submissions across internal departments
• Maintain oversight of policy coverage, limits, and reporting requirements
• Oversee and participate in timely reporting of actual and potential claims to applicable carriers, including First Notice of Loss (FNOL)
• Provide claims loss runs and certificates of insurance (COIs) for providers and organizational needs
• Oversee processes related to provider coverage, including new provider quotes and extended reporting period (tail) coverage for departing providers
• Maintain insurance documentation and renewal timelines

Claims-to-Safety Integration

• Collaborate with the Director of Risk and Patient Safety and Risk Analyst to share trends, themes, and lessons learned from claims and litigation activity
• Contribute to the development of prevention strategies by translating claim experience into actionable insights
• Support structured communication of aggregated claim themes and closed-case learning to leadership and medical staff

Operational Coordination

• Maintain organized workflows and documentation to support consistent claims and insurance operations
• Coordinate meetings, reporting, and documentation related to claims and insurance activities
• Support departmental planning and improvement initiatives
• Contribute to cross-training and knowledge sharing within the Risk & Patient Safety department

Qualifications

Required

• Bachelor’s degree in healthcare administration, business, nursing, or related field
• 3+ years of experience in claims management, healthcare risk management, insurance operations, or related field
• Experience working with claims management systems (e.g., RLDatix or similar)
• Strong organizational, analytical, and problem-solving skills, including experience analyzing data to identify trends and inform decision-making
• Ability to manage multiple complex processes simultaneously, ensuring accuracy and compliance
• Excellent communication and collaboration skills, with the ability to work across departments and with external partners

Preferred

• Claims adjuster experience or certification
• Experience with self-insured trusts or healthcare insurance programs
• Familiarity with healthcare regulatory reporting requirements
• Experience working with legal counsel and litigation processes