Clinical Review Nurse

AmTrust Financial Services•Princeton, NJ

6d•Hybrid

About The Position

AmTrust Financial Services, a fast-growing commercial insurance company, has a need for 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.

Requirements

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 required to include 2+ years of direct clinical care OR 2+ years of utilization management required.
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
Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization; fosters 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
Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Computer keyboarding
Hearing, vision and talking

Nice To Haves

Bachelor's degree in nursing (BSN) from 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.

Responsibilities

Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional guidelines.
Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered.
Responsible for helping to 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 assesses 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.
Responsible for accurate comprehensive documentation of Utilization Review activities in the case management and pharmacy benefit management systems.
Responsible for completing timely reviews according to state’s requirements and communicating the UR determination to all parties.
Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care.
Communicates effectively with providers, claims adjuster, client, and other parties as needed to expedite appropriate medical care
Keeps current with market trends and demands.
Performs other functionally related duties as assigned