Major Case Manager

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 employeeproviderand 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

• Uses clinical/nursingexpertisetodeterminewhether all aspects of a patients care at every level are medically necessary and appropriately delivered.
• Improve the quality of life with the overall goal ofreturnto preinjury status.Assistthe injured employee and family to secureoptimalcare and achieve full recovery.
• Perform Utilization Review activities prospectivelyconcurrentlyor 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 individuals treatment program while maximizing quality and costeffectiveness of care including direction of care to preferred provider networks where applicable.
• Establishes effective return to work plans with employer injured employeeproviderand 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 employees functional assessment.
• Responsible for helping to ensure injured employees receiveappropriate leveland intensity of care through use of medical and disability duration guidelinesdirectly 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 vendorsupervisorand other parties as needed to negotiatecoordinateappropriate 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 clients situation to include psychosocial needs culturalimplicationsand support systems in place
• Objectively and critically assesses all information related to the current treatment plan toidentifybarriersclarifyordeterminerealistic 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 clients 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 organizations quality program(s).

Education & Licensing:

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

Bachelors 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 CRRNetc.

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 experienceto include two 2 years of direct clinical care AND three 3 years of combination of either case management/managed care setting/discharge planning/utilization management.
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 ODGUtilizationreview 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 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 workrelated stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical:Computer keyboarding
Auditory/Visual:Hearing vision and talking

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.