Medical Review Nurse

Novacore Insurance Services; United States; Híbrido; USD 70.000 - 100.000; Tempo integral

Resumo da vaga

Novacore Insurance Services seeks a Medical Review Nurse to support underwriters with clinical and claims data evaluation, risk assessment, and catastrophe claim management. Hybrids options include Conshohocken, PA or Minneapolis, MN offices, with remote capabilities.

The role requires an active RN license (preferred), CCM considered, and at least one year of acute care experience. Strong data handling, communication, and MS Office skills are essential for success.

Qualificações

• 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 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 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.

Responsabilidades

• 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.

Conhecimentos

Communication skills

Time management

Organization

Remote collaboration

Formação

Bachelor’s degree in nursing or science

CCM certification

Ferramentas

MS Office

Descrição da vaga

Why join the Novacoreteam?

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.

But at our core, we believe it’s not just what we do — it’s 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.