Jobs at Nova Healthcare Administrators, Inc.

Adjudicate and adjust medical and dental claims per plan policies, research and resolve coding/payment issues, maintain accuracy and productivity targets, respond to member/provider inquiries, and communicate with internal teams to ensure correct claim payments and process improvements.

Senior Clinical & Coding Specialist reviews complex inpatient coding and clinical cases, conducts audits, validates diagnosis/procedure coding, manages appeals and external dispute processes, trains staff, analyzes audit trends, recalculates reimbursement, and presents audit results to leadership.

Integrate multiple healthcare data sources to produce reports and complex analyses of quality measure trends, support HEDIS/QARR submissions, model gap-closure opportunities, develop custom measures, present findings, validate data, and lead improvement initiatives while mentoring junior analysts.

Prepare and review journal entries, monthly/annual financial statements (GAAP and SAP methods), reconciliations and variance analyses. Generate audit schedules and management reports using Workday/report writers, investigate and resolve month-end differences, support tax return preparation, and improve accounting processes to meet deadlines.

Provide post-discharge transition-of-care case management for members, conducting telephonic outreach, assessing needs, developing and documenting care plans, coordinating with interdisciplinary teams, addressing barriers, and ensuring regulatory compliance to reduce readmissions and improve outcomes.

Manage projects end-to-end using Waterfall, Agile, or hybrid approaches. Define scope, schedule, budget, risks, and success criteria; lead cross-functional teams; facilitate ceremonies and stakeholder communication; support business readiness, change management, and continuous improvement; ensure documentation, governance compliance, and transition to operations.

Manage retention and growth of self-funded client memberships (<500 subscribers). Analyze healthcare cost drivers, recommend solutions, lead client and broker meetings, resolve benefits and billing issues, support claims, onboard clients, and meet productivity goals while maintaining detailed renewal and engagement records.

Provide phone-based support to healthcare providers: answer benefit/eligibility, billing, payment, and EOB questions; research and resolve escalated claims inquiries; document contacts; meet call center quality and productivity standards; escalate as needed and educate providers on errors and system/billing issues.

Provide RN case management including assessment, care planning, implementation, coordination, monitoring and evaluation. Advocate for patients, coordinate with payors and providers, ensure regulatory compliance, document care plans, identify barriers and alternative levels of care, and utilize community resources to optimize patient outcomes.

Independently investigate and resolve member and provider complaints and appeals by researching policies, contracts, claims systems, and clinical documentation. Collaborate with internal and external stakeholders, document findings accurately, ensure regulatory compliance and timely responses, provide member education on benefits and coverage determinations, and identify trends and process improvements to support department goals.

Perform QA audits and monitoring across lines of business to ensure regulatory compliance (CMS, NYS DOH, NYS DFS), develop and run manual/automated tests, log and track defects, produce reports, conduct internal audits, analyze trends, and collaborate with cross-functional teams to remediate findings and improve processes.