Gil Nechushtai
Chief Product Officer at Five Sigma
Gil is an experienced insurance technology leader with over two decades of success in crafting InsurTech solutions. His expertise spans developing AI platforms and streamlining operational efficiency.
6 MINUTE READ
For decades, insurance claims operations have relied on two key actors: claims professionals (mainly adjusters) and claims systems. Adjusters brought know-how, judgment, experience, and empathy. Claims management systems (CMS) brought documentation, structure, control, and consistency.
But as claim volumes surged, new Lines of Business evolved, and customer expectations for fast and accurate service grew, CMS (typically outdated legacy systems) couldn’t keep up. Adjusters became burdened with administrative overhead, filling forms, toggling between screens, and re-entering data, leaving less time for high-value decisions and customer care.
Most claims systems proved too rigid to adapt to the changing insurance landscape. Newly emerged tools often layered on more complexity, instead of simplifying workflows. The result? Slower processing, higher leakage, and frustrated teams & customers.
AI is a New Actor in Claims Management
Today, a new, third actor has entered the picture: artificial intelligence. Not just as another feature, but a true participant in the claims lifecycle. AI observes, interprets, decides, and acts – and in doing so, reshapes the roles and responsibilities and how work gets done.
But to fully benefit from this transformation, insurers must pause and ask: What is the job-to-be-done (JBTD) for each part of the claim’s journey? What is the new role distribution between the three actors?
In this blog, I’ll define the roles of human, system, and AI in the modern claims operation, to show how they can work in harmony, each focused on what they do best.
Yesterday’s Claims Handling Model: People and Systems
In the classic setup, roles were straightforward. The adjuster was the mind and heart: reading, thinking, interpreting, making decisions, and logging everything along the way.
The CMS served as the backbone: organizing workflows, keeping records, enforcing business rules, and maintaining compliance.
But this two-actor model placed a heavy cognitive load on adjusters. They carried the responsibility for sensitive customer interactions and nuanced decisions, but also had to manage every procedural detail to keep the process moving.
The result was an operational imbalance: too much effort spent on tasks that didn’t require human judgment.
As claim volumes increased and processes grew more complex, the cracks in the model widened. More dashboards didn’t reduce the cognitive load. More tools didn’t eliminate the noise. The claims handling system didn’t scale. Instead, it strained.
The New Model: AI Enters the Claims Handling Scene
The introduction of AI into the claims process changes the equation. AI isn’t just a backend tool or automation feature, it’s a new contributor to the operation. The right AI agent can orchestrate an entire claim from FNOL to settlement. It adds intelligence and speed where structure alone cannot.
At Five Sigma, we follow an automation-first philosophy. In my work leading Five Sigma’s product, we constantly ask: what can be automated, and what should be left to human judgment? The goal isn’t to remove people from the process, it’s to remove work that doesn’t require them. The AI agent is a direct expression of this approach: a tool designed to take on repetitive, procedural tasks so that adjusters and managers can focus on the parts of the claim that truly require expertise, nuance, and oversight.
Today’s modern claims team includes three distinct roles:
- The AI agent, which enhances both CMS and adjuster by taking on routine and manual work, offering recommendations, and highlighting risks or insights in real time.
- The CMS, which continues to provide structure, compliance, and reporting.
- The adjuster, focused on high-value decision-making and sensitive communication.
The introduction of the AI agent helps shift the balance by alleviating the burden from adjusters, helping them focus on the human aspect they bring to the equation, and their unique job-to-be-done.
The AI Agent: The Operational Claims Intelligence Layer
The role of the AI agent is to alleviate the operational burden on both adjusters and systems, acting as an active third participant in the claim’s journey.
The AI agent delivers value by:
- Reducing manual effort: Summarizing claim history, generating documentation, auto-completing standard language.
- Guiding prioritization: Flagging sensitive cases, SLA risks, high-severity incidents.
- Highlighting issues and risks: Missing data, noncompliant timelines, contradictory narratives and fraudulent behavior.
- Acting as an expert-on-demand: Providing policy interpretations, historical claim patterns, and behavioral nudges drawn from peer actions.
- Ensuring compliance: Understanding regulatory requirements and prompting for specific actions or language.
- Accelerating resolution: Auto-drafting decisions for low-complexity claims, recommending next steps in complex ones.
The AI agent empowers adjusters, helping them navigate large volumes of claims with ease. It shortens the path to resolution, improves consistency, and ensures no important detail slips through the cracks.
The Claims Management System: From Record Keeper to Operational Core
The role of the CMS is to enable efficient, compliant, and scalable claims resolution across the organization. It is the infrastructure for order. It governs workflow, enforces compliance, connects teams, and ensures auditability. It brings consistency to an inherently complex and messy process.
The CMS is essential for handling claims. But it is not adaptive. It doesn’t interpret context, draft communications, or make decisions. It doesn’t learn. That’s where AI steps in.
An intelligently designed CMS that incorporates AI agents, automates steps based on business logic, surfaces critical information like policy terms and claim history, and tracks timelines and SLAs across jurisdictions. It enables managers to monitor performance and maintain control, even at scale.
The Adjuster: From Claim Execution to High-Leverage Judgment
Adjusters remain at the center of the claims management process, not as processors, but as expert interpreters of complexity. Their job-to-be-done is to apply judgment where rules and data alone fall short. They assess gray areas, weigh competing narratives, and navigate sensitive moments with empathy and professionalism.
In a world where AI agents handle repeatable tasks and the CMS enforces structure, adjusters are the ones who ensure the claim is resolved fairly, ethically, and humanely. In many ways, the adjuster is the face of the insurer. The person customers remember when their claim is handled fairly, clearly, and with care. It’s through the adjuster’s decisions and demeanor that trust is built – or lost. With AI, the adjuster’s role becomes more concentrated: fewer distractions, higher stakes, greater impact.
Clive™: The Insurance Industry’s First AI Claims Adjuster
At Five Sigma, we’ve built Clive™, our AI Claims Adjuster, to serve as a fully integrated third actor in the claims lifecycle, on top of any claims management system.
Clive is more than a tool; he’s your best colleague. He brings a deep understanding of the insurance claims ecosystem – claims data, policy structures, workflows, and compliance requirements. He monitors every detail in real time, keeps processes moving, and steps in wherever guidance or clarification is needed. He helps adjusters stay focused on the work that requires judgment, empathy, and expertise. Clive is always aligned with your rules, always ready to assist.
With Clive on the team, your claims operation becomes faster, sharper, and easier to scale—without compromising quality or control.
Operational Claims Harmony Starts With the Right Job-to-Be-Done
The future of claims handling isn’t about replacing people; it’s about redefining the right roles. When adjusters, systems, and AI agents each focus on what they do best, claims get handled faster, more accurately, and with a better customer experience. With Clive, insurers can unlock this new model today – boosting efficiency, reducing leakage, and empowering adjusters to deliver real value where it counts most.
Ready to add the right third actor to your claims operation?
