The Medical Case Manager provides comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider, and employer. The Medical Case Manager is empathetic, informative, and collaborative. This position coordinates medical resources for our injured employees and partners with the AmTrust Claims Adjuster team to develop a personalized holistic approach for each claim. Maintains a solid understanding of AmTrust's mission, vision, and values. Upholds the standards of the AmTrust organization.
- 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 necessary
- Responsible 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 place.
- Objectively 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 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).
- Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.
- Keeps current with market trends and demands.
- Performs other functionally related duties as assigned.
- Active unrestricted RN license in a state or territory of the United States with eligibility to get and/or renew a multistate license .
- 5+ years of related experience or equivalent combination of education and experience required to include 2+ years of direct clinical care OR 2+ years of case management/utilization management required.
- National Certification in case management OR the ability to obtain certification within 24 months of employment is 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 referred
- Proficiency in all Microsoft Office products including Project, Word, Excel, PowerPoint, Visio, and SharePoint
- Knowledge of workers' compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, Utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed
- Excellent oral and written communication, including presentation skills
- Leadership/management/motivational skills as well as analytic and strong organizational skills
- Ability to work in a team environment and to meet or exceed Performance Competencies
This job description is designed to provide a general overview of the requirements of the job and does not entail a comprehensive listing of all activities, duties, or responsibilities that will be required in this position. AmTrust has the right to revise this job description at any time.
What We Offer:
AmTrust Financial Services offers a great work environment, competitive compensation package and excellent career advancement opportunities. Our benefits include: Medical and Dental Plans, Life Insurance, Health Care Flexible Spending, Dependent Care, 401k Savings Plans, and 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.
AmTrust Financial Services is committed to a policy of Equal Employment Opportunity.