Utilization Review Assistant Jobs in Edison, NJ (NOW HIRING)

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

• 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 plans utilizing critical thinking skills, clinical expertise and other resources needed to achieve an optimal case outcome.  
• Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place 
• Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify or determine realistic goals and objectives, and seek potential alternatives. 
• Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome 
• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.  
• Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director).  

• Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves  
• Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards. 
• May assist in training/orientation of new staff as requested 
• Other duties may be assigned. 
• Supports the organization's quality program(s). 

Education & Licensing:

Active unrestricted RN license in a state or territory of the United States required.

Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred.

Certification in case management, rehabilitation nursing or a related specialty is highly preferred (CCM, COHN, CRRN, etc).

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. Written and verbal fluency in Spanish and English preferred

Experience:

Minimum Five (5) years of related experience required to include two (2) years of direct clinical care AND three (3) years of combination of either case management/managed care setting/discharge planning/utilization management required. 
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