Hmo Claim Manager Jobs (NOW HIRING)

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.

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.

The Managed Care Claims Analyst is a healthcare claims professional who will evaluate and adjudicate reinsurance claims on HMO reinsurance, provider stoploss and medical excess contracts. To succeed in this role, the ideal candidate should be analytical, resourceful and self-motivated.

The Managed Care Claims Analyst should be an excellent communicator, who is willing to speak up and offer ideas and suggestions. Willingness to jump in and independently advance projects and key priorities is welcomed.

Carbon Stop Loss Solutions, part of Novacore's Healthcare Segment, 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.

Responsibilities:

• Promote, build and maintain relationships with clients and brokers.
• Receive and interpret claim submissions in a variety of formats. Perform initial evaluation to ensure submissions are complete.
• Review and fully adjudicate claims according to reinsurance agreements.
• Validate claims for reimbursement, including application of detailed industry repricing methodologies.
• Provide key reporting metrics to clients. Respond to inquiries and resolve appeals and pending claims as needed.
• Collaborate on the development and enhancement of Carbon's proprietary claim adjudication software and systems. Work closely with developers to maximize efficiency and ensure all claim department needs are met.
• Appropriately escalate difficult issues up the chain of command, as needed.
• Provide outstanding customer service and collaborate with other departments, management, and external partners/leaders.
• Provide guidance and training to team/more Jr. level employees on claim review processes, policy interpretation, and best practices when needed.
• Assist team/managers in quality assurance audits to ensure adherence to company standards.

Qualifications:

• 5+ years' experience preferably working with medical claims.
• Proficiency with claim industry pricing methodology including Medicare DRG, RBRVS, transplant contracts and PPO networks.
• Strong Microsoft Office skills, particularly Outlook, Excel and Word.
• Strong written and oral communication skills.
• Skillful at managing multiple priorities and handling interruptions.
• Work independently and as part of a team.
• Can-do attitude is key; eager to jump in and roll up your sleeves.
• Working knowledge of insurance terminology and medical coding.