Medical Review Nurse

Novacore•Conshohocken, PA

5d•Hybrid

About The Position

The Medical Review Nurse is a registered nurse who assists Novacore’s Claim and Underwriting Departments in managing risk and mitigating claims exposure. The role supports timely clinical and claims-data evaluation during the disclosure process, catastrophic claim management, claims analysis, and medical underwriting tasks. The position is hybrid, based three days onsite at either the Conshohocken, Pennsylvania Home Office or the Minneapolis, Minnesota Carbon Office.

Requirements

At least one year of acute care clinical experience.
UM or CM experience on either the payer or provider side.
Prior experience analyzing health care claims and coding.
Prior experience working with catastrophic health care claims.
Experience with data entry and analysis of medical reporting.
Ability to provide risk assessment and communicate analysis succinctly in reporting.
Ability to conduct independent medical research as an adjunct to medical underwriting tasks.
Ability to meet tight time frames.
Strong organizational and time management skills.
Ability to work independently in a remote setting.
Ability to work with multiple offices and underwriters and prioritize time frames.
Strong data entry skills.
Proficiency with MS Office software.
Ability to communicate effectively and professionally internally and with external clients.

Nice To Haves

Registered Nurse licensure is preferred.
A bachelor’s degree in nursing or science is preferred.
CCM certification is preferred.
Prior TPA, MGU, or stop-loss carrier experience is highly preferable.

Responsibilities

Assist underwriters in the timely evaluation of clinical and claim data during the disclosure process to identify potential risk.
Work with Third-Party Administrators and producers as a medical resource for discussion and assistance with potential catastrophic claim management.
Assist Case Managers employed by TPAs or outside firms with high-dollar catastrophic claimants.
Evaluate claims reporting for potential exposure and reserve recommendations.
Conduct clinical review and claims analysis to assess claim trends and possible group resources.
Maintain patient confidentiality in compliance with standards set forth by IOA and HIPAA.
Work with the department manager to seek and employ new business partners that promote health care resources and mitigate claims exposure.
Serve as a back-up for other department medical staff as needed.
Maintain licensure and certifications to promote personal professional advancement.