Medical Case Manager
Medical Case Manager
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Job Description
Overview
AmTrust Financial Services a fast growing commercial insurance company has a need for a 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 patients 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 individuals treatment program while maximizing quality and costeffectiveness 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 employees functional assessment.
- Responsible for helping to ensure injured employees receiveappropriate level and intensity of care through use of medical and disability duration guidelinesdirectly 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 tocoordinate appropriate medical care and return to work.
- Performs clinical assessment via information in medical/pharmacy reports and case files; assesses clients 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 clients 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 organizations quality program(s).
Qualifications
Education & Licensing
- Active unrestricted California RN license.
- Bachelors 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 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 workrelated stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical:Computer keyboarding
Auditory/Visual:Hearing vision and talking
- Able to sit (approx. 75100 of the time) and stand (approx. 025 of the time)
- Able to type (approx. 75100 of the time)
- Able to lift push pull carry up to 15 lbs
- Able to reach at or above shoulder height
The salary range for this role is $80000$91000/year. This range is only applicable for jobs to be performed in California. Base pay offered may vary depending on but not limited to education experience skills geographic location travel requirements sales or revenuebased metrics. This range may be modified in the future
#LIGH1
#LIHYBRID
#AMTRUST
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
Required Experience:
Manager
Employment Type
Full-Time
