Claims Analyst, Managed Care

Novacore•Conshohocken, PA

About The Position

The Managed Care Claims Analyst is a healthcare claims professional who will evaluate and adjudicate reinsurance claims on HMO reinsurance, provider stoploss and medical excess contracts. To succeed in this role, the ideal candidate should be analytical, resourceful and self-motivated. The Managed Care Claims Analyst should be an excellent communicator, who is willing to speak up and offer ideas and suggestions. Willingness to jump in and independently advance projects and key priorities is welcomed. Carbon Stop Loss Solutions, part of Novacore’s Healthcare Segment, is a leading managing general underwriter (MGU) in the field of employer stop loss and managed care insurance. Carbon’s team of experts are known as the industry leader in delivering best-in-class risk solutions to effectively lower healthcare costs. Carbon’s offerings support clients and brokers in a rapidly changing healthcare market with best-in-class service, underwriting, claims support and effective cost containment strategies.

Requirements

5+ years’ experience preferably working with medical claims.
Proficiency with claim industry pricing methodology including Medicare DRG, RBRVS, transplant contracts and PPO networks.
Strong Microsoft Office skills, particularly Outlook, Excel and Word.
Strong written and oral communication skills.
Skillful at managing multiple priorities and handling interruptions.
Work independently and as part of a team.
Can-do attitude is key; eager to jump in and roll up your sleeves.
Working knowledge of insurance terminology and medical coding.

Responsibilities

Promote, build and maintain relationships with clients and brokers.
Receive and interpret claim submissions in a variety of formats. Perform initial evaluation to ensure submissions are complete.
Review and fully adjudicate claims according to reinsurance agreements.
Validate claims for reimbursement, including application of detailed industry repricing methodologies.
Provide key reporting metrics to clients. Respond to inquiries and resolve appeals and pending claims as needed.
Collaborate on the development and enhancement of Carbon’s proprietary claim adjudication software and systems. Work closely with developers to maximize efficiency and ensure all claim department needs are met.
Appropriately escalate difficult issues up the chain of command, as needed.
Provide outstanding customer service and collaborate with other departments, management, and external partners/leaders.
Provide guidance and training to team/more Jr. level employees on claim review processes, policy interpretation, and best practices when needed.
Assist team/managers in quality assurance audits to ensure adherence to company standards.