Major Loss Case Manager (Registered Nurse)

Overview AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Complex Care Case Manager, RN for Workers Compensation managed care team. PRIMARY PURPOSE: The complex care case manager will provide comprehensive and quality telephonic case management for our injured employees with complex diagnoses and often catastrophic injuries. Our nurses will be responsible for proactively applying clinical expertise ensuring our injured employees receive medically appropriate healthcare to achieve a safe return to work or best optimal level of function through engagement with the injured employee, provider and employer. Our nurses will be empathetic informative medical resources for our injured employees, and they will partner with our adjusters to develop a personalized holistic approach for each claim. These responsibilities may include utilization review, pharmacy oversight and care coordination Responsibilities Uses clinical/nursing expertise to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered. Improve the quality of life with the overall goal of return to pre-injury status. Assist the injured employee and family to secure optimal care and achieve full recovery. Perform Utilization Review activities prospectively, concurrently or retrospectively in accordance with the appropriate jurisdictional guidelines. Coordination of medically appropriate care where multiple services may be needed such as discharge planning for hospitalizations, pain and symptom management, home health, provider home visits, home based palliative care or assistance with daily living activities. Responsible for accurate comprehensive documentation of case management activities in case management system. This includes documenting medical and disability case management strategies for claim resolution, based on clinical expertise. Adheres to confidentiality policy. Includes written correspondence as needed to prescribing physician(s) and refers to physician advisor as necessary Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable. Establishes effective return to work plans with employer, injured employee, provider and other parties as needed. Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee’s functional assessment. Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the compensable injury and/or assist adjusters in managing medical treatment to drive resolution. Communicates effectively both verbal and written with medical professionals, claims adjuster, client, vendor, supervisor and other parties as needed to negotiate, coordinate appropriate medical care and effective return to work pla