Major Loss Case Manager

Overview

AmTrust Financial Services, afast growingcommercial insurance company, has a need for a Complex Care Case Manager, RN for Workers Compensation managed care team.

PRIMARY PURPOSE: Thecomplex care case manager will provide comprehensive and quality telephonic case management for our injured employees with complex diagnoses and often catastrophic injuries. Our nurses willbe responsible forproactively applying clinicalexpertiseensuring our injured employees receive medicallyappropriate healthcareto achieve a safe return to work or bestoptimallevel of function through engagement with the injured employee,providerand employer. Our nurses will be empathetic informative medical resources for our injured employees, and they will partner with our adjusters to develop a personalizedholistic approachfor each claim. These responsibilities may includeutilizationreview, pharmacy oversight and care coordination

Responsibilities

• Uses clinical/nursingexpertisetodeterminewhether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered.
• Improve the quality of life with the overall goal ofreturnto pre-injury status.Assistthe injured employee and family to secureoptimalcare and achieve full recovery.
• Perform Utilization Review activities prospectively,concurrentlyor retrospectivelyin accordance withtheappropriate jurisdictionalguidelines.
• Coordination of medicallyappropriate carewhere multiple services may be needed such as discharge planning for hospitalizations, pain and symptom management, home health, provider home visits, home based palliative care orassistancewith daily living activities.
• Responsible foraccuratecomprehensive documentation of case management activities in case management system. This includes documenting medical and disability case management strategies for claim resolution, based on clinicalexpertise. Adheres to confidentiality policy.Includes written correspondence as needed to prescribing physician(s) and refers to physician advisor as necessary
• 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.
• Establishes effective return to work plans with employer, injured employee,providerand other parties as needed. Addresses need for job description and appropriately discusses with employer, injuredemployeeand/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 receiveappropriate leveland intensity of care through use of medical and disability duration guidelines,directly relatedto the compensable injury and/orassistadjusters in managing medical treatment to drive resolution.
• Communicates effectively both verbal and written with medical professionals, claims adjuster, client, vendor,supervisorand other parties as needed to negotiate,coordinateappropriate medicalcare and effective return to work plansutilizingcritical thinking skills, clinicalexpertiseand other resources needed to achievean optimalcase outcome.
• Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client's situation to include psychosocial needs, culturalimplicationsand support systems in place
• Objectively and critically assesses all information related to the current treatment plan toidentifybarriers,clarifyordeterminerealistic goals andobjectives, and seek potential alternatives.
• Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or theappropriate 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 achieveoptimalresolution (behavioral health program, physician advisor, peer reviews, medical director).

• Partner with adjuster to provide input on medical treatment and recovery time toassistin evaluatingappropriate claimreserves
• Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards.
• Mayassistin training/orientation ofnew staffas requested
• Other duties may be assigned.
• Supports the organization's quality program(s).

Qualifications

Education & Licensing:

Active unrestricted RN license in a state or territory of the United Statesrequired.

Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred.

Certification in case management, rehabilitation nursing or a related specialty is highly preferred (CCM, COHN, CRRN,etc).

Acquisition and maintenance of Insurance License(s) maybe requiredtocomply withstate 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

Experience:

Minimum Five (5) years of related experiencerequiredto include two (2) years of direct clinical care AND three (3) years of combination of either case management/managed care setting/discharge planning/utilization managementrequired. Preferredpreviousclinical experience emergency room, critical care, home care or rehab experience.

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,Utilizationreview, state workers compensation guidelines

Knowledge of pharmaceuticals to treat pain, pain management process, drug rehabilitationKnowledge 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 andnegotiation skills Ability to work in a team environment Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

When applicable andappropriate, consideration will be given to reasonableaccommodations. 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 keyboardingAuditory/Visual: Hearing, vision and talking

The expected salary range for this role is $87,600.00-$97,000.00

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.

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What We Offer

AmTrust Financial Services offers a competitive compensation package and excellent career advancement opportunities. Our benefits include: Medical & Dental Plans, Life Insurance, including eligible spouses & children, Health Care Flexible Spending, Dependent Care, 401k Savings Plans, Paid Time Off.

AmTrust strives to create a diverse and inclusive culture where thoughts and ideas of all employees are appreciated and respected. This concept encompasses but is not limited to human differences with regard to race, ethnicity, gender, sexual orientation, culture, religion or disabilities.

AmTrust values excellence and recognizes that by embracing the diverse backgrounds, skills, and perspectives of its workforce, it will sustain a competitive advantage and remain an employer of choice. Diversity is a business imperative, enabling us to attract, retain and develop the best talent available. We see diversity as more than just policies and practices. It is an integral part of who we are as a company, how we operate and how we see our future.