Medical Review Nurse

Novacore; Pennsylvania; Hybrid; USD 75,000 - 100,000; Full time

Benefits offered by this job

A collaborative, results-driven env

Competitive compensation and benefits

Year-round social and community events

Ongoing mentorship and professional发展

Endless opportunities for upwardMob

Job summary

Novacore, a leading specialty insurer, is seeking a Medical Review Nurse to join our Healthcare Segment. The nurse will assist underwriters and case managers, review clinical data, and help manage high-dollar claims while maintaining patient confidentiality.

Ideal candidates are registered nurses with CCM, strong data skills, and the ability to work in a hybrid schedule from Conshohocken, PA or Minneapolis, MN.

Qualifications

• Registered Nurse licensure preferred; bachelor’s degree in nursing or science.
• CCM certification preferred.
• At least one year of acute care clinical experience required.
• UM or CM experience on either payer or provider side.
• Prior experience analyzing health care claims and coding.
• Ability to work independently in a remote setting and meet tight time frames.

Responsibilities

• Assist underwriters in evaluating clinical and claim data during disclosure to identify risk.
• Collaborate with TPAs and producers as a medical resource for catastrophic claim management.
• Assist Case Managers with high dollar catastrophic claimants.
• Evaluate claims reporting for exposure and reserve recommendations.
• Conduct clinical review and claims analysis to identify trends and resources.
• Maintain patient confidentiality per HIPAA and IOA standards.
• Support department managers in promoting health care resources and mitigating exposure.
• Act as back-up for other medical staff as needed.

Skills

Communication skills

Organizational skills

Time management

Remote work ability

Data entry

MS Office

Education

Bachelor’s degree in nursing or science

Registered Nurse licensure preferred

CCM certification, preferred

Tools

MS Office

Job description

Why join the Novacore team?

Because your next stellar chapter starts here — and we’re building something bold and meaningful.At Novacore, we’re not your average insurance company. We’re a team of driven professionals passionate about redefining the specialty insurance experience for our agents, carrier partners — and for each other.

Why join the Novacore team?Because your next stellar chapter starts here — and we’re building something bold and meaningful.At Novacore, we’re not your average insurance company. We’re a team of driven professionals passionate about redefining the specialty insurance experience for our agents, carrier partners — and for each other. We specialize in tailored solutions for niche industries, powered by advanced analytics, modern technology and a culture of innovation. Backed by strong leadership and strategic growth initiatives, Novacore is poised to scale and lead in the specialty insurance market.But at our core, we believe it’s not just what we do — it how we do it and who we do it with. Recognized as a top workplace, Novacore is a place where ambition is supported, growth is continuous and culture matters. From day one, you’ll find mentorship, hands-on learning and clear paths for advancement. You’ll grow your skills, expand your expertise and become even more exceptional — because when you succeed, we all do.

We Offer

• A collaborative, results-driven environment
• Competitive compensation and comprehensive benefits
• Year-round social and community events
• Ongoing mentorship and professional development
• Endless opportunities for upward mobility

So if you're ready to be part of something extraordinary — with a team that’s transforming commercial insurance — we want to meet you.

Medical Review Nurse

Carbon Stop Loss Solutions 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. Carbon Stop Loss Solutions makes up Novacore’s Healthcare Segment. At Novacore, we’re entering an exciting new chapter. Novacore is the newly formed specialty insurance entity created from the April 2025 sale of NSM Insurance Group’s U.S. commercial division. We’re building something bold and meaningful, and every team member plays a vital role in that mission. The Medical Review Nurse is a registered nurse who can assist Novacore’s Claim and Underwriting Departments in managing risk and mitigating claims exposure.

• Ideally, we’re looking for candidates that can work on a hybrid schedule from the Conshohocken, PA Home Office, or the Minneapolis, MN, Carbon Office**

Responsibilities

• Assist underwriters in the timely evaluation of clinical and claim data during the disclosure process to identify potential risk.
• Work with our Third-Party Administrators and producers as a medical resource for discussion and assistance with potential catastrophic claim management.
• Assist Case Managers, either employed by our TPAs, or with outside firms, with high dollar catastrophic claimants.
• Evaluate claims reporting for potential exposure and reserve recommendations.
• Clinical review and claims analysis to assess for claim trends and possible group resources.
• Maintain patient confidentiality in compliance with standards set forth by IOA 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.

Qualifications

• Registered Nurse licensure preferred - bachelor’s degree in nursing or science.
• CCM certification, preferred.
• At least one year of acute care clinical experienced, required.
• UM or CM experience on either the payer or provider side.
• Prior TPA, MGU or Stop loss carrier experience is highly preferable.
• 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.
• Strong data entry skills.
• Proficient with MS Office software.
• Ability to communicate effectively and professionally both internally and with external clients.