Medical Case Manager
Company: AmTrust Financial Services, Inc.
Location: Boca Raton
Posted on: May 16, 2022
|
|
Job Description:
Overview
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.
Responsibilities
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 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
Experience
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
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
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
Auditory/Visual : Hearing, vision and talking
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.
Keywords: AmTrust Financial Services, Inc., Boca Raton , Medical Case Manager, Executive , Boca Raton, Florida
Click
here to apply!
|