Medical Management Nurse

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: 1.On assigned case management cases, assesses severity of the injury, evaluates treatment plans and the extent of disability, and collaborates with all applicable parties in order to establish goals that facilitate a safe/timely return to work as well as to achieve maximum functional restoration for the injured worker. 2.Ensures the privacy and security of Protected Health Information (PHI). 3.Consistent and effective communication with injured workers, medical professionals, administrative assistants, claims staff, employers and all stake holders is a primary responsibility. 4.Responds to various written and telephone inquiries in a timely manner regarding the status of the case. 5.Engages in the proper use of resources including various vendors and other applicable resources to achieve optimal outcomes on each case. 6.Consistently maintains confidentiality on any/all cases, professional, positive and appropriate communications, accurate documentation including goals, interventions, recommendations and decisions regarding assigned case management cases. 7.Prioritizes and coordinates multiple responsibilities while working closely with internal and external customers. 8.Document the use of best practice references such as standardized disability duration guidelines and medical management resources/references utilized while performing case management assessments, activities and interventions. 9.Functions as a clinical resource to administrative assistants, claims staff, employers and injured workers. 10.Reports any actual or potential quality issues or potential serious medical treatment concern issues to the Lead Medical Management Nurse. 11.Limited local travel may be required for occasional field/site visits. 12.Maintains billable hours appropriate to role and assigned accounts. 13.Must be able to work at least 40 hours per week, Monday thru Friday and be available to work extended hours as situations arise. 14.Negotiation skills are necessary to establish and facilitate treatment. 15.May be required to work overtime as assigned. 16.Keeps current with market trends and demands. 17.Performs other functionally related duties as assigned. Qualifications: Required: •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. •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 •Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. •Ability to respond to common inquiries or complaints from customers, regulatory and governmental agencies, attorneys, or members of the business community. •Ability to write letters, memos and reports that conform to prescribed style, format and grammatical correctness. •Ability to effectively present information to top management, in claims and in client settings. Strong written and verbal communication skills in order to effectively communicate with injured workers, medical professionals, employers, Claims staff and others. •Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages. •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. •Current unrestricted California RN license. A valid class “C” Motor Vehicle Operators license as issued by the State of California. Physical Requirements: •May sit, stand, stoop, bend, and ambulate intermittently during the day. •May need to sit or stand for extended periods. •May need to lift up to twenty-five (25) pounds on occasion. •Due to the nature of this role, physical presence in the office is required. 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. 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 $38.46-43.27/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.

 

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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.