Teams at Nova Healthcare Administrators, Inc.

Analyzes healthcare quality data from claims, membership, provider, EMR, ADT, and risk-score sources. Develops reports, dashboards, forecasts, quality measure models, and gap-closure analyses; validates findings and communicates recommendations. Supports HEDIS and QARR submissions, regulatory reporting, auditor responses, performance improvement initiatives, new data-source integration, and cross-functional quality workgroups.

Adjudicates and adjusts medical and dental claims according to client plan criteria, policies, coding requirements, and regulations. Reviews payment explanations, researches coding and benefit issues, resolves claim discrepancies, responds to member, provider, and client inquiries, and meets productivity, accuracy, and timeliness goals. Maintains benefit and contract knowledge, navigates claims systems, manages workload, and communicates with internal departments to resolve payment problems.

The Case Manager assesses patients’ medical, psychosocial, and social needs; develops and monitors care plans; coordinates interdisciplinary providers, payors, community resources, and alternative care services; advocates for patients; evaluates quality and cost effectiveness; ensures regulatory, privacy, reimbursement, and documentation compliance; and supports care management training and staff development.