Medical Management Nurse

1 month ago

Fresno, United States AmTrust Financial Full time

Overview:

The Medical Management Nurse reports directly to the Director, Medical Case Management. Performs nursing interventions and/or telephonic case management activities, including prioritizing and managing a caseload of medical and disability workers compensation claims.

Has the responsibility of reviewing the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the AmTrust Claims Adjuster team to expedite medically necessary treatment for each claim. Will also review pharmacy authorizations to determine appropriateness of pharmaceutical treatment.

This candidate must be able to channel authorized treatment within the Medical Provider Network and effectively negotiate treatment plans. Provides medical case management through collaboration and communication to promote quality and cost-effective outcomes. Functions as a patient advocate.

Responsibilities:

Responsibilities:

    • On assigned case management cases, assesses severity of the injury, evaluates treatment plans and the extent of disability, and collaborates with all applicable parties to establish goals that facilitate a safe/timely return to work as well as to achieve maximum functional restoration for the injured worker.
    • Uses clinical/nursing skills to determine whether all aspects of a patients 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 assesses 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.
    • Uses clinical/nursing skills to help coordinate the individuals treatment program while maximizing quality and cost-effectiveness of care.
    • Communicates effectively with providers, claims adjuster, client, and other parties as needed to expedite appropriate medical care
    • Responds to various written and telephone inquiries in a timely manner regarding the status of the case.
    • Engages in the proper use of resources including various vendors and other applicable resources to achieve optimal outcomes on each case.


Qualifications:

Qualifications

  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
  • The requirements listed below are representative of the knowledge, skill, and/or ability required.
  • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

  • Graduate of accredited Registered Nursing Program.
  • Current unrestricted California RN license.
  • Bachelor of Science in Nursing (BSN) desirable.
  • Strong clinical background in orthopedics, emergency room, intensive care, neurology, occupational medicine, or rehabilitation useful. Strong cost containment background, such as utilization review or managed care also useful.
  • One to two plus years of recent clinical experience and/or one to two years of recent managed care experience.
  • Achieves recognized certification in case management within company-designated timeframes

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.
  • Strong written and verbal communication skills to effectively communicate with injured workers, medical professionals, employers, claims staff and others.
  • Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization; fosters an environment of shared responsibility and accountability.

REASONING ABILITY:

  • Ability to define problems, collect data, establish facts, and draw valid conclusions.

Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. Must have strong organizational, problem solving and time management skills. Sound professional judgement.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The salary range for this role is $43.26-44.47/hour. This range is only applicable for jobs to be performed in California. 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.

#LI-GH1

#LI-REMOTE

What We Offer:

AmTrust Financial Services offers a competitive compensation package and excellent career advancement opportunities. Our benefits include: Medical & Dental Plans, Life Insurance, including eligible spouses & children, Health Care Flexible Spending, Dependent Care, 401k Savings Plans, 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.

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