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.
• Communicates effectively with claims adjusters, clients, vendors, supervisors, and other parties as needed to coordinate appropriate medical care and return to work.
• Conducts clinical assessments 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.
• 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).
• Presents 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.