Medical Review Nurse

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’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.

Responsibilities

• Aid underwriters in the timely evaluation of clinical and claim data during the disclosure process to identify potential risk.
• Collaborate with Third-Party Administrators and producers as a medical resource for discussion and assistance with potential catastrophic claim management.
• Support Case Managers, either employed by Carbon’s TPAs, or with outside firms, in handling high-dollar catastrophic claimants.
• Evaluate claims reporting for potential exposure and provide reserve recommendations.
• Conduct clinical reviews and claims analyses to assess claim trends and explore possible group resources.
• Maintain patient confidentiality in compliance with standards set forth by Carbon as well as HIPAA.
• Seek and employ new business partners to promote health care resources and mitigate claims exposure.
• Serve as a backup for other department medical staff as needed.
• Maintain licensure and certifications as indicated to promote personal professional advancement.

Qualifications

• Registered Nurse active license required - BSN preferred.
• CCM certification, preferred.
• At least one year of acute care clinical experience.
• 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.
• 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.
• Effective communication skills, both internally and with external clients.