Medical Review Nurse

Novacore•Conshohocken, PA

18h•Remote

About The Position

Novacore is seeking a Medical Review Nurse to join their Carbon Stop Loss Solutions team. This role involves assisting Novacore's Claim and Underwriting Departments in managing risk and mitigating claims exposure. Carbon Stop Loss Solutions is a leading managing general underwriter (MGU) specializing in employer stop loss and managed care insurance, known for delivering effective risk solutions to lower healthcare costs. The Medical Review Nurse will act as a medical resource, evaluate claims, and contribute to cost containment strategies within a rapidly changing healthcare market.

Requirements

Registered Nurse active license required
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.
Provide risk assessment and communicate the 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.
Proficient with MS Office software.
Ability to communicate effectively and professionally both internally and with external clients.

Nice To Haves

BSN preferred.
CCM certification, 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, either employed by Carbon’s TPAs, or with 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 Carbon as well as HIPAA.
Work with the department manager in seeking and employing new business partners to promote health care resources and mitigate claims exposure.
Serve as a back-up for other department medical staff as needed.
Maintain licensure and certifications as indicated to promote personal professional advancement.