Remote Medical Review Nurse: Claims Risk & Underwriting

Novacore Insurance Services; United States; Híbrido; USD 70.000 - 100.000; Jornada completa

Descripción de la vacante

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.

Formación

• 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.

Conocimientos

Communication skills

Time management

Organization

Remote collaboration

Educación

Bachelor’s degree in nursing or science

CCM certification

Herramientas

MS Office

Descripción del empleo

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.