Telephonic Nurse Case Manager - California RN

Telephonic Nurse Case Manager - California RN Required

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AmTrust Financial Services, a fast‑growing commercial insurance company, needs a Telephonic Medical Case Manager, RN.
PRIMARY

PURPOSE:

Provide comprehensive, high‑quality telephonic case management to proactively drive medically appropriate return‑to‑work outcomes through engagement with injured employees, providers, and employers. Our nurses serve as empathetic, informative medical resources for employees and partner with adjusters to develop personalized holistic approaches for each claim, including utilization review, pharmacy oversight, and care coordination.

• Use 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 jurisdictional guidelines.
• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary.
• Document case management activities accurately in the case management system.
• Help coordinate the individual’s treatment program, maximizing quality and cost‑effectiveness of care, including directing care to preferred provider networks when applicable.
• Discuss job‑description needs with employer, injured employee, and/or provider; work with employers on job‑duty modifications based on medical limitations and functional assessment.
• 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 assist adjusters in managing medical treatment to drive resolution.
• Communicate effectively with claims adjusters, clients, vendors, supervisors, and other parties to coordinate appropriate medical care and return‑to‑work plans.
• Perform clinical assessment using medical/pharmacy reports and case files; assess client’s psychosocial needs, cultural implications, and support systems.
• 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 for maximal medical improvement or 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; adhere to ethical, legal, accreditation, and regulatory standards.
• Assist in training/orientation of new staff as requested.
• Other duties may be assigned.
• Support the organization’s quality program(s).

• Active unrestricted RN license in California is required. Arizona license 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 is highly preferred.
• Ability to acquire and maintain appropriate professional certifications and licenses to comply with state laws; license(s) to be obtained within three to six months of starting the job.
• Written and verbal fluency in Spanish and English preferred.

Five (5) years of related experience or 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 necessary treatment.
• Knowledge of URAC standards, ODG, utilization review, and state workers’ compensation guidelines.
• Knowledg…