Healthcare Utilization Review Specialist

2 weeks ago

Dallas Texas, United States AmTrust Financial Services, Inc. Full time

Overview:


AmTrust Financial Services, a rapidly expanding commercial insurance provider, is seeking a Healthcare Utilization Review Specialist for remote or office-based work.


PRIMARY PURPOSE:

The Healthcare Utilization Review Specialist is tasked with evaluating the medical necessity, suitability, quality, and efficiency of services provided to Workers' Compensation claimants.

This role involves assessing the medical appropriateness of suggested treatments and medications for injured employees, collaborating with the AmTrust Claims Adjuster team to facilitate timely access to necessary medical care for each claim.

Additionally, the specialist reviews pharmacy authorizations to ascertain the appropriateness of pharmaceutical interventions. A thorough understanding of AmTrust's mission, vision, and values is essential, along with a commitment to uphold the organization's standards.

Responsibilities:
Conduct Utilization Review activities prospectively, concurrently, or retrospectively in line with relevant jurisdictional guidelines.


Employ clinical/nursing expertise to evaluate whether all facets of a patient's care are medically necessary and appropriately administered.


Ensure that injured employees receive the correct level and intensity of care directly associated with their compensable injuries, utilizing industry-standard and/or state-specific medical treatment guidelines and formularies.

Objectively assess all information pertinent to the current treatment request to make informed medical necessity determinations.

Issue determination letters as required to the requesting physician(s) and refer to physician advisors for secondary reviews when necessary.

Maintain accurate and comprehensive documentation of Utilization Review activities within case management and pharmacy benefit management systems.

Complete reviews in a timely manner according to state regulations and communicate the UR determination to all involved parties.

Utilize clinical/nursing skills to help coordinate the individual's treatment plan while maximizing the quality and cost-effectiveness of care.

Effectively communicate with providers, claims adjusters, clients, and other stakeholders to expedite appropriate medical treatment.

Stay informed about market trends and demands.

Perform other related duties as assigned.

Qualifications:


Possession of an active, unrestricted RN license in a state or territory of the United States, with eligibility for obtaining and/or renewing a multistate license.


A minimum of 5 years of relevant experience or an equivalent combination of education and experience, including at least 2 years of direct clinical care or 2 years of utilization management.

Education & Licensing

A Bachelor's degree in nursing (BSN) from an accredited institution or equivalent work experience is preferred. Certification in case management, pharmacy, rehabilitation nursing, or a related specialty is highly desirable.

Acquisition and maintenance of Insurance License(s) may be necessary to comply with state regulations, with a preference for licenses to be obtained within three to six months of employment.

Skills & Knowledge

Proficiency in Microsoft Office Suite, including Project, Word, Excel, PowerPoint, Visio, and SharePoint.

Familiarity with workers' compensation laws and regulations, behavioral health, case management practices, URAC standards, ODG, utilization review, pain management pharmaceuticals, drug rehabilitation, state workers' compensation guidelines, periods of disability, and necessary treatments.

Exceptional oral and written communication skills, including presentation abilities.

Capacity to collaborate effectively within a multi-functional team and throughout the organization, fostering a culture of shared responsibility and accountability.

Strong organizational, communication, and analytical skills.

Excellent negotiation capabilities.

Able to thrive in a team-oriented environment.

Ability to meet or exceed performance competencies.

#LI-GH1

#LI-HYBRID

What We Offer:
AmTrust Financial Services provides a competitive compensation package along with excellent opportunities for career advancement.

Our benefits include:

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


AmTrust is committed to fostering a diverse and inclusive culture where the thoughts and ideas of all employees are valued and respected.

This commitment encompasses various human differences, including race, ethnicity, gender, sexual orientation, culture, religion, and disabilities.


AmTrust values excellence and recognizes that embracing the diverse backgrounds, skills, and perspectives of its workforce is crucial for maintaining a competitive edge and being an employer of choice.

Diversity is a business imperative, enabling us to attract, retain, and develop top talent. We view diversity as more than just policies and practices; it is integral to our identity as a company, how we operate, and how we envision our future.

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