Clinical Review Nurse

AmTrust Financial Services; Lewisville (TX); Remote; USD 70,000 - 90,000; Full time

Job summary

AmTrust Financial Services recherche un Clinical Review Nurse pour évaluer la nécessité médicale et l'efficacité des services pour les demandeurs d'indemnisation des travailleurs. Ce poste demande un leadership clinique solide et encourage les candidats ayant l'esprit d'équipe et de bonnes compétences de communication. Les candidats doivent avoir une licence RN active au Texas et plusieurs années d'expérience pertinente.

Benefits

Compensation compétitive

Avancement de carrière

Assurances santé, dentaire, vie

401k

Congés payés

Qualifications

• Licence RN active et sans restriction au Texas.
• Plus de 5 ans d'expérience pertinente, avec au moins 2 ans en soins cliniques ou en gestion d'utilisation.

Responsibilities

• Réaliser des activités de révision d'utilisation en suivant les directives jurisprudentielles.
• Évaluer la nécessité et l'adéquation des soins aux patients.

Skills

Communication

Analyse

Négociation

Organisation

Education

Bachelor's degree in nursing (BSN)

Tools

Microsoft Office Suite

SharePoint

Job description

Overview

AmTrust Financial Services, a fast-growing commercial insurance company, has a need for a Clinical Review Nurse, either remote or in an office location.

PRIMARY PURPOSE: The Clinical Review Nurse is responsible for reviewing the medical necessity, appropriateness, quality, and efficiency of services for Workers’ Compensation claimants. This role assesses the medical appropriateness of treatments and medications, partnering with the AmTrust Claims Adjuster team to expedite necessary treatment. They also review pharmacy authorizations to ensure pharmaceutical treatments are appropriate. The nurse maintains a solid understanding of AmTrust’s mission, vision, and values, upholding organizational standards.

Responsibilities:

1. Perform Utilization Review activities prospectively, concurrently, or retrospectively, following jurisdictional guidelines.
2. Use clinical/nursing skills to determine the necessity and appropriateness of all aspects of patient care.
3. Ensure injured employees receive appropriate care related to their injury, following medical guidelines and formularies.
4. Objectively assess treatment requests to determine medical necessity.
5. Send determination letters to physicians and refer to physician advisors for second reviews as needed.
6. Accurately document Utilization Review activities in case management and pharmacy systems.
7. Complete timely reviews and communicate determinations to all parties.
8. Coordinate treatment programs to maximize quality and cost-effectiveness.
9. Communicate effectively with providers, claims adjusters, and clients to expedite care.
10. Stay current with market trends and demands.
11. Perform other related duties as assigned.

Qualifications:

• Active unrestricted RN license in Texas.
• 5+ years of related experience or equivalent, including 2+ years of clinical care or utilization management.

Education & Licensing:

• Bachelor's degree in nursing (BSN) or equivalent work experience preferred.
• Certification in case management, pharmacy, rehabilitation nursing, or related fields is highly preferred.
• Insurance licenses may be required, to be obtained within 3-6 months of starting.

Skills & Knowledge:

• Proficiency in Microsoft Office Suite and SharePoint.
• Knowledge of workers' compensation laws, URAC standards, pharmaceuticals, pain management, and related regulations.
• Excellent communication, presentation, negotiation, organizational, and analytical skills.
• Ability to work collaboratively in a team environment and meet performance standards.

What We Offer:

Competitive compensation, career advancement, and benefits including medical, dental, life insurance, flexible spending, 401k, and paid time off. We value diversity and strive to create an inclusive culture that respects all employees and perspectives.