AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Telephonic Medical Case Manager, RN.
PRIMARY PURPOSE: To provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider and employer. Our nurses will be empathetic informative medical resources for our injured employees and they will partner with our adjusters to develop a personalized holistic approach for each claim. These responsibilities may include utilization review, pharmacy oversight and care coordination.
- Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level, are medically necessary and appropriately delivered.
- Perform Utilization Review activities prospectively, concurrently or retrospectively in accordance with the appropriate jurisdictional guidelines.
- Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary
- Responsible for accurate comprehensive documentation of case management activities in case management system.
- Uses clinical/nursing skills to help coordinate the individual's treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable.
- Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee's functional assessment.
- Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the compensable injury and/or assist adjusters in managing medical treatment to drive resolution.
- Communicates effectively with claims adjuster, client, vendor, supervisor and other parties as needed to coordinate appropriate medical care and return to work.
- Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place
- Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify or determine realistic goals and objectives, and seek potential alternatives.
- Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome
- Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.
- Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director).
- Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves
- Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards.
- May assist in training/orientation of new staff as requested
- Other duties may be assigned.
- Supports the organization's quality program(s).
Qualifications Education & Licensing
Active unrestricted CA RN license in a state or territory of the United States required . Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred. Acquisition and maintenance of Insurance License(s) may be required to comply with state requirements. Preferred for license(s) to be obtained within three - six months of starting the job. Written and verbal fluency in Spanish and English preferred
Five (5) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management required. Skills & Knowledge:
Knowledge of workers' compensation laws and regulations
Knowledge of case management practice
Knowledge of the nature and extent of injuries, periods of disability, and treatment needed
Knowledge of URAC standards, ODG, Utilization review, state workers compensation guidelines
Knowledge of pharmaceuticals to treat pain, pain management process, drug rehabilitation
Knowledge of behavioral health
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Analytic and interpretive skills
Strong organizational skills
Excellent interpersonal and negotiation skills
Ability to work in a team environment
Ability to meet or exceed Performance Competencies WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.
Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding
Hearing, vision and talking