AmTrust Financial
Overview
AmTrust Financial Services, a fast-growing commercial insurance company, has a need for a Clinical Review Nurse remote or in an office location.
Primary purpose:
The Clinical Review Nurse has the responsibility of reviewing the medical necessity, appropriateness, quality and efficiency of services in the appropriate setting for Workers' Compensation claimants. This position assesses the medical appropriateness of proposed treatments and medications for our injured employees, partners with the AmTrust Claims Adjuster team to expedite medically necessary treatment for each claim, and reviews pharmacy authorizations to determine appropriateness of pharmaceutical treatment. Maintains a solid understanding of AmTrust's mission, vision, and values. Upholds the standards of the AmTrust organization.
Responsibilities
Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional guidelines.
Use clinical/nursing skills to determine whether all aspects of a patient's care, at every level, are medically necessary and appropriately delivered.
Responsible for helping to ensure injured employees receive appropriate level and intensity of care directly related to the compensable injury using industry standard and/or state specific medical treatment guidelines and formularies.
Objectively and critically assess all information related to the current treatment request to make the appropriate medical necessity determination.
Sends determination letters as needed to requesting physician(s) and refers to physician advisors for second level reviews as necessary.
Responsible for accurate comprehensive documentation of Utilization Review activities in the case management and pharmacy benefit management systems.
Responsible for completing timely reviews according to state's requirements and communicating the UR determination to all parties.
Use clinical/nursing skills to help coordinate the individual's treatment program while maximizing quality and cost-effectiveness of care.
Communicate effectively with providers, claims adjuster, client, and other parties as needed to expedite appropriate medical care.
Keep current with market trends and demands.
Perform other functionally related duties as assigned.
Qualifications 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, including 2+ years of direct clinical care OR 2+ years of utilization management.
Education & Licensing
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.
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.
Skills & Knowledge
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.
Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization; foster an environment of shared responsibility and accountability.
Strong organizational, communication and analytical skills.
Excellent negotiation skills.
Ability to work in a team environment.
Ability to meet or exceed Performance Competencies.
Work Environment When 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
Medical & Dental Plans
Life Insurance, including eligible spouses & children
Health Care Flexible Spending
Dependent Care
401k Savings Plans
Paid Time Off
Connect With Us Not ready to apply? Connect with us for general consideration.
The salary range for this role is $80,000-92,500/year. This range is only applicable for jobs to be performed in New York. Base pay offered may vary depending on, but not limited to education, experience, skills, geographic location, travel requirements, sales or revenue-based metrics. This range may be modified in the future.
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.
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Primary purpose:
The Clinical Review Nurse has the responsibility of reviewing the medical necessity, appropriateness, quality and efficiency of services in the appropriate setting for Workers' Compensation claimants. This position assesses the medical appropriateness of proposed treatments and medications for our injured employees, partners with the AmTrust Claims Adjuster team to expedite medically necessary treatment for each claim, and reviews pharmacy authorizations to determine appropriateness of pharmaceutical treatment. Maintains a solid understanding of AmTrust's mission, vision, and values. Upholds the standards of the AmTrust organization.
Responsibilities
Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional guidelines.
Use clinical/nursing skills to determine whether all aspects of a patient's care, at every level, are medically necessary and appropriately delivered.
Responsible for helping to ensure injured employees receive appropriate level and intensity of care directly related to the compensable injury using industry standard and/or state specific medical treatment guidelines and formularies.
Objectively and critically assess all information related to the current treatment request to make the appropriate medical necessity determination.
Sends determination letters as needed to requesting physician(s) and refers to physician advisors for second level reviews as necessary.
Responsible for accurate comprehensive documentation of Utilization Review activities in the case management and pharmacy benefit management systems.
Responsible for completing timely reviews according to state's requirements and communicating the UR determination to all parties.
Use clinical/nursing skills to help coordinate the individual's treatment program while maximizing quality and cost-effectiveness of care.
Communicate effectively with providers, claims adjuster, client, and other parties as needed to expedite appropriate medical care.
Keep current with market trends and demands.
Perform other functionally related duties as assigned.
Qualifications 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, including 2+ years of direct clinical care OR 2+ years of utilization management.
Education & Licensing
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.
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.
Skills & Knowledge
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.
Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization; foster an environment of shared responsibility and accountability.
Strong organizational, communication and analytical skills.
Excellent negotiation skills.
Ability to work in a team environment.
Ability to meet or exceed Performance Competencies.
Work Environment When 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
Medical & Dental Plans
Life Insurance, including eligible spouses & children
Health Care Flexible Spending
Dependent Care
401k Savings Plans
Paid Time Off
Connect With Us Not ready to apply? Connect with us for general consideration.
The salary range for this role is $80,000-92,500/year. This range is only applicable for jobs to be performed in New York. Base pay offered may vary depending on, but not limited to education, experience, skills, geographic location, travel requirements, sales or revenue-based metrics. This range may be modified in the future.
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.
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