Clinical Review Nurse

Overview

Job Location s: US-NJ-Princeton | US-NY-Latham | US

Requisition  | Category:
Managed Care | Position Type:
Regular Full-Time

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, and partners with the AmTrust Claims Adjuster team to expedite medically necessary treatment for each claim. They also review 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.

This position will be hybrid out of one of our AmTrust office locations!

• 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.
• 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.
• Accurately document Utilization Review activities in the case management and pharmacy benefit management systems.
• Complete reviews timely according to state requirements and communicate the UR determination to all parties.
• 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 to expedite appropriate medical care.
• Keep current with market trends and demands.
• Perform other functionally related duties as assigned.

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, 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 is 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.

• Collaborate 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,…