AmTrust Financial Services, Inc.
Clinical Review Nurse
AmTrust Financial Services, a fast‑growing commercial insurance company, is looking for a Clinical Review Nurse to work remotely or in an office location.
Primary Purpose Review medical necessity, appropriateness, quality, and efficiency of services for Workers’ Compensation claimants, assessing medical appropriateness of treatments and medications, partnering with the AmTrust Claims Adjuster team, expediting medically necessary treatment, and reviewing pharmacy authorizations.
Responsibilities
Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with jurisdictional guidelines.
Use clinical/nursing skills to determine medical necessity and appropriate delivery of care.
Ensure injured employees receive appropriate level and intensity of care related to the compensable injury using industry standards / state-specific guidelines.
Objectively assess treatment requests to make medical necessity determinations.
Send determination letters as needed and refer to physician advisors for second level reviews.
Document Utilization Review activities in case management and pharmacy benefit management systems.
Complete reviews timely according to state requirements and communicate determinations.
Coordinate individual treatment programs while maximizing quality and cost‑effectiveness.
Communicate effectively with providers, claims adjuster, client, and other parties to expedite appropriate care.
Keep current with market trends and demands.
Perform other functionally related duties as assigned.
Qualifications
Active unrestricted RN license in a U.S. state with eligibility to obtain a multistate license.
5+ years of related experience or equivalent, including 2+ years of direct clinical care or 2+ years of utilization management.
Bachelor’s degree in nursing (BSN) preferred; related specialty certifications highly preferred.
Education & Licensing
BSN from an accredited institution or equivalent work experience.
Acquisition and maintenance of insurance licenses may be required; preference for licenses obtained within 3–6 months.
Skills & Knowledge
Proficiency in Microsoft Office (Project, Word, Excel, PowerPoint, Visio, SharePoint).
Knowledge of workers' compensation laws, behavioral health, case management, URAC standards, utilization review, pharmaceuticals, pain management, and state guidelines.
Excellent oral and written communication, presentation skills.
Collaborative teamwork and organizational skills.
Strong analytical and negotiation skills.
Ability to meet or exceed performance competencies.
Work Environment
Consideration will be given to reasonable accommodations.
Physical: Computer keyboarding.
Auditory/Visual: Hearing, vision, talking.
Mental: Clear thinking, judgment, problem solving, deadline orientation.
Salary Range $80,000—$92,500 per year (New York). Base pay may vary based on education, experience, and location.
Benefits
Medical & Dental Plans
Life Insurance (including spouses & children)
Health Care Flexible Spending
Dependent Care
401(k) Savings Plans
Paid Time Off
What We Offer Competitive compensation and excellent career advancement opportunities. AmTrust fosters a diverse and inclusive culture, valuing excellence and broad perspectives.
#J-18808-Ljbffr
Primary Purpose Review medical necessity, appropriateness, quality, and efficiency of services for Workers’ Compensation claimants, assessing medical appropriateness of treatments and medications, partnering with the AmTrust Claims Adjuster team, expediting medically necessary treatment, and reviewing pharmacy authorizations.
Responsibilities
Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with jurisdictional guidelines.
Use clinical/nursing skills to determine medical necessity and appropriate delivery of care.
Ensure injured employees receive appropriate level and intensity of care related to the compensable injury using industry standards / state-specific guidelines.
Objectively assess treatment requests to make medical necessity determinations.
Send determination letters as needed and refer to physician advisors for second level reviews.
Document Utilization Review activities in case management and pharmacy benefit management systems.
Complete reviews timely according to state requirements and communicate determinations.
Coordinate individual treatment programs while maximizing quality and cost‑effectiveness.
Communicate effectively with providers, claims adjuster, client, and other parties to expedite appropriate care.
Keep current with market trends and demands.
Perform other functionally related duties as assigned.
Qualifications
Active unrestricted RN license in a U.S. state with eligibility to obtain a multistate license.
5+ years of related experience or equivalent, including 2+ years of direct clinical care or 2+ years of utilization management.
Bachelor’s degree in nursing (BSN) preferred; related specialty certifications highly preferred.
Education & Licensing
BSN from an accredited institution or equivalent work experience.
Acquisition and maintenance of insurance licenses may be required; preference for licenses obtained within 3–6 months.
Skills & Knowledge
Proficiency in Microsoft Office (Project, Word, Excel, PowerPoint, Visio, SharePoint).
Knowledge of workers' compensation laws, behavioral health, case management, URAC standards, utilization review, pharmaceuticals, pain management, and state guidelines.
Excellent oral and written communication, presentation skills.
Collaborative teamwork and organizational skills.
Strong analytical and negotiation skills.
Ability to meet or exceed performance competencies.
Work Environment
Consideration will be given to reasonable accommodations.
Physical: Computer keyboarding.
Auditory/Visual: Hearing, vision, talking.
Mental: Clear thinking, judgment, problem solving, deadline orientation.
Salary Range $80,000—$92,500 per year (New York). Base pay may vary based on education, experience, and location.
Benefits
Medical & Dental Plans
Life Insurance (including spouses & children)
Health Care Flexible Spending
Dependent Care
401(k) Savings Plans
Paid Time Off
What We Offer Competitive compensation and excellent career advancement opportunities. AmTrust fosters a diverse and inclusive culture, valuing excellence and broad perspectives.
#J-18808-Ljbffr