Medical Case Manager

Overview

AmTrust Financial Services, a fast-growing commercial insurance company, seeks a Telephonic Medical Case Manager, RN. The primary purpose is 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.

Responsibilities

• Determines if all aspects of a patient’s care are medically necessary and appropriately delivered.
• Performs Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional guidelines.
• Sends letters as needed to prescribing physicians and refers to physician advisors as necessary.
• Accurately documents case management activities in the case management system.
• Coordinates the individual’s treatment program while maximizing quality and cost-effectiveness of care, including directing care to preferred provider networks where applicable.
• Addresses the need for job descriptions and appropriately discusses with employers, injured employees, and/or providers.
• Works with employers on job duty modifications based on medical limitations and the employee’s functional assessment.
• Helps ensure injured employees receive appropriate levels and intensities of care through use of medical and disability duration guidelines directly related to the compensable injury, and assists adjusters in managing medical treatment to drive resolution.
• Communicates effectively with claims adjusters, clients, vendors, supervisors, and other parties as needed to coordinate appropriate medical care and return to work.
• Performs clinical assessments via information in medical/pharmacy reports and case files; assesses client’s situation, including 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.
• Pairs with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome.
• Evaluates and updates treatment and return to work plans within established protocols throughout the life of the claim.
• Engages specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director).
• Partners with the 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.
• Supports the organization’s quality program(s).

Qualifications

• Active unrestricted NY RN license in required, NJ Compact is preferred.
• 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.
• Ability to acquire and maintain appropriate Professional Certifications and Licenses to comply with respective state laws may be required.
• Preferred for licenses to be obtained within three to 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, including two (2) years of direct clinical care or two (2) years of case management/utilization management.

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, and state workers compensation guidelines.
• Knowledge of pharmaceuticals to treat pain, pain management process, and drug rehabilitation.
• Knowledge of behavioral health.
• Excellent oral and written communication, including presentation skills.
• PC literate, including Microsoft Office products.
• Leadership/management/motivational skills.
• 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.

What We Offer

• Competitive compensation package.
• Excellent career advancement opportunities.
• Medical & Dental Plans.
• Life Insurance, including eligible spouses & children.
• Health Care Flexible Spending.
• Dependent Care.
• 401k Savings Plans.
• Paid Time Off.

Benefits

• Medical & Dental Plans.
• Life Insurance, including eligible spouses & children.
• Health Care Flexible Spending.
• Dependent Care.
• 401k Savings Plans.
• Paid Time Off.

Salary Range

The expected salary range for this role is $80,000.00-$90,000.00. Please note that the salary information shown above is a general guideline only. Salaries are based upon a wide range of factors considered in making the compensation decision, including, but not limited to, candidate skills, experience, education and training, the scope and responsibilities of the role, as well as market and business considerations.