Medical Case Manager

Overview

AmTrust Financial Services, a fast-growing commercial insurance company, has a need for a Telephonic Medical Case Manager, RN.

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 serve as empathetic, informative medical resources for our injured employees and partner with adjusters to develop a personalized, holistic approach for each claim. These responsibilities may include utilization review, pharmacy oversight, and care coordination.

This position is remote with a preference for working hybrid out of one of our AmTrust office locations.

• Use clinical/nursing skills to determine whether all aspects of a patient’s care are medically necessary and appropriately delivered.
• Perform utilization review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional guidelines.
• Send letters as needed to prescribing physician(s) and refer to physician advisor as necessary.
• Maintain accurate comprehensive documentation of case‑management activities in the case‑management system.
• Coordinate the individual’s treatment program while maximizing quality and cost‑effectiveness of care, including directing care to preferred provider networks where applicable.
• Discuss job‑fit with employer, injured employee, and/or provider; work with employers on modifications to job duties based on medical limitations and the employee’s functional assessment.
• Ensure injured employees receive appropriate level and intensity of care through use of medical and disability‑duration guidelines, and assist adjusters in managing medical treatment to drive resolution.
• Communicate effectively with claims adjuster, client, vendor, supervisor, and other parties as needed to coordinate appropriate medical care and return to work.
• Perform clinical assessment via medical/pharmacy reports and case files; assess client’s psychosocial needs, cultural implications, and support systems in place.
• Objectively and critically assess all information related to the current treatment plan to identify barriers, clarify or determine realistic goals, and seek potential alternatives.
• Partner 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).
• Provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.
• Maintain client privacy and confidentiality; promote client safety and advocacy; and adhere to ethical, legal, accreditation, and regulatory standards.
• Assist in training/orientation of new staff as requested.
• Perform other duties as assigned.
• Support the organization’s quality program(s).

• Active unrestricted NY RN license required; NJ Compact preferred.
• Bachelor’s degree in nursing (BSN) from an accredited college or university, or equivalent work experience preferred.
• Certification in case management, pharmacy, rehabilitation nursing, or a related specialty highly preferred.
• Ability to acquire and maintain appropriate professional certifications and licenses to comply with state laws may be required.
• Preferred that licenses be obtained within three to six months of starting the job.
• Fluency in Spanish and English preferred.

Five (5) years of related experience or an equivalent combination of education and experience required, including two (2) years of direct clinical care or two (2) years of case management/utilization management.

• 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, and state workers’ compensation guidelines.
• Knowledge of…