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About the Role

AmTrust Financial Services seeks a Telephonic Medical Case Manager, RN to provide comprehensive telephonic case management, driving a medically appropriate return to work through engagement with the injured employee, provider, and employer. This role serves as an empathetic and informative medical resource, partnering with adjusters to develop personalized, holistic claim approaches, potentially including utilization review, pharmacy oversight, and care coordination.

Responsibilities

Use clinical/nursing skills to determine medical necessity and appropriate delivery of patient care.
Perform prospective, concurrent, or retrospective Utilization Review in accordance with jurisdictional guidelines.
Send letters to prescribing physicians and refer to a physician advisor as necessary.
Accurately document case management activities in the case management system.
Coordinate treatment programs using clinical/nursing skills to maximize quality and cost-effectiveness of care.
Address the need for job descriptions and discuss with employers, injured employees, and/or providers.
Work with employers on job duty modifications based on medical limitations and functional assessments.
Ensure injured employees receive appropriate levels and intensity of care using medical and disability duration guidelines.
Assist adjusters in managing medical treatment to drive resolution.
Communicate effectively with claims adjusters, clients, vendors, supervisors, and other parties to coordinate care and return to work.
Perform clinical assessments using medical/pharmacy reports and case files.
Assess client situations, including psychosocial needs, cultural implications, and support systems.
Critically assess treatment plans to identify barriers, set realistic goals, and seek alternatives.
Partner with adjusters to develop medical resolution strategies for maximal medical improvement.
Evaluate and update treatment and return-to-work plans within established protocols.
Engage specialty resources as needed for optimal resolution.
Provide input to adjusters on medical treatment and recovery time to assist in reserve evaluation.
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.
Support the organization's quality programs.

Requirements

Active unrestricted NY RN license; NJ Compact preferred.
Ability to acquire and maintain appropriate Professional Certifications and Licenses as required by state laws.
Written and verbal fluency in Spanish and English preferred.
Five (5) years of related experience or equivalent combination of education and experience.
Two (2) years of direct clinical care OR two (2) years of case management/utilization management experience required.

Skills

Clinical/nursing skills
Utilization Review
Case management documentation
Care coordination
Communication
Interpersonal skills
Negotiation skills
Teamwork
Performance Competency achievement
Workers' compensation laws and regulations
Case management practice
Knowledge of the nature and extent of injuries, periods of disability, and treatment needed
URAC standards
ODG
Utilization review
State workers' compensation guidelines
Pharmaceutical knowledge for pain treatment and drug rehabilitation
Behavioral health knowledge
Excellent oral and written communication
Presentation skills
PC literate
Microsoft Office products
Leadership/management/motivational skills
Analytic and interpretive skills
Strong organizational skills
Clear and conceptual thinking ability
Excellent judgment
Troubleshooting
Problem solving
Analysis
Discretion
Ability to handle work-related stress
Ability to handle multiple priorities simultaneously
Ability to meet deadlines

Location

Remote
Hybrid (preference for working out of an AmTrust office location)

Work Type

Remote
Hybrid

Experience Level

5 years of related experience
2 years of direct clinical care
2 years of case management/utilization management

Education Level

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.
Professional Certifications and Licenses

Salary/Compensations

$80,000.00-$90,000.00

Benefits

Medical & Dental Plans
Life Insurance, including eligible spouses & children
Health Care Flexible Spending
Dependent Care
401k Savings Plans
Paid Time Off

About the Company

AmTrust Financial Services is a fast-growing commercial insurance company.
AmTrust Financial Services offers a competitive compensation package and excellent career advancement opportunities.
AmTrust strives to create a diverse and inclusive culture where thoughts and ideas of all employees are appreciated and respected.
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.
Diversity is an integral part of who we are as a company, how we operate and how we see our future.

Equal Opportunity

This concept encompasses but is not limited to human differences with regard to race, ethnicity, gender, sexual orientation, culture, religion or disabilities.