Medical Case Manager
Company: AmTrust Financial Services, Inc.
Location: Alpharetta
Posted on: June 25, 2022
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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
necessaryResponsible 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
placeObjectively 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 outcomeEvaluate 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 reservesMaintains 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 requestedOther
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
preferredExperienceFive (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 practiceKnowledge of the nature and
extent of injuries, periods of disability, and treatment needed
Knowledge of URAC standards, ODG, Utilization review, state workers
compensation guidelinesKnowledge 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 ENVIRONMENTWhen 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.
-#LI-BE1#LI-HYBRID
Keywords: AmTrust Financial Services, Inc., Alpharetta , Medical Case Manager, Executive , Alpharetta, Georgia
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