Clinical Review Nurse

Clinical Review Nurse

Job Locations

US-NY-Latham | US-NJ-Princeton | US-NH-Nashua

Requisition ID

JR1004947

Category

Managed Care

Position Type

Regular Full-Time

Overview

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.

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

Qualifications

Active unrestricted RN license in a state or territory of the United States with eligibility to get and / or renew a multistate license.

Education & Licensing

Skills & Knowledge

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, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical : Computer keyboarding

Auditory / Visual : Hearing, vision and talking

The salary range for this role is $80,000-92,500 / year. This range is only applicable for jobs to be performed in New York. 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.

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. AmTrust has the right to revise this job description at any time.

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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.

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