Major Loss Case Manager (Registered Nurse)

Overview AmTrust Financial Services, a fast‑growing commercial insurance company, seeks a Complex Care Case Manager, RN to join our Workers Compensation managed care team. Primary Purpose Provide comprehensive telephonic case management for injured employees with complex diagnoses, ensuring medically appropriate care to achieve a safe return to work or optimal functioning. Collaborate with adjusters to develop personalized holistic approaches. Duties 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. Improves quality of life with the overall goal of return to pre‑injury status; assists the injured employee and family to secure optimal care and achieve full recovery. Performs utilization review activities prospectively, concurrently, or retrospectively in accordance with jurisdictional guidelines. Coordinates medically appropriate care when multiple services are needed (e.g., discharge planning, pain and symptom management, home health, provider visits, palliative care, or assistance with daily living activities). Documents case management activities accurately in the system, including medical and disability strategies, confidentiality compliance, and written correspondence as needed. Co‑coordinates treatment programs to maximize quality and cost‑effectiveness, directing care to preferred provider networks when applicable. Establishes effective return to work plans with employer, employee, provider, and other parties; addresses job description and discusses modifications based on medical limitations. Ensures employees receive appropriate intensity of care using medical and disability duration guidelines; assists adjusters in managing medical treatment for claim resolution. Communicates effectively verbally and in writing with medical professionals, claims adjusters, clients, vendors, supervisors, and other parties to negotiate, coordinate care, and achieve optimal outcomes. Performs clinical assessment from reports and case files; evaluates psychosocial needs, cultural implications, and support systems. Objectively assesses treatment information to identify barriers, clarify realistic goals, and seek alternatives. Partners with adjuster to develop treatment strategies for maximal medical improvement or appropriate outcomes. Evaluates and updates treatment and return to work plans within established protocols throughout claim life. Engages specialty resources as needed (behavioral health, physician advisor, peer review, medical director). Provides input on medical treatment and recovery time to assist in evaluating claim reserves. Maintains client privacy, promotes safety and advocacy, and adheres to ethical, legal, accreditation, and regulatory standards. Assists with training or orientation of new staff as requested. Other duties may be assigned. Supports the organization's quality programs. Qualifications Education & Licensing Active unrestricted RN license in a U.S. state or territory required. Bachelor’s degree in nursing (BSN) or equivalent work experience preferred. Certification in case management, rehabilitation nursing, or a related specialty (e.g., CCM, COHN, CRRN) highly preferred. Acquisition and maintenance of insurance license(s) may be required by state; preferred within 3‑6 months of start date. Written and verbal fluency in Spanish and English preferred. Experience Minimum five (5) years of related experience, including two (2) years of direct clinical care and three (3) years of case management/managed care, discharge planning, or utilization management. Preferred previous clinical experience in emergency room, critical care, home care, or rehabilitation. Skills & Knowledge Knowledge of workers’ compensation laws and regulations. Knowledge of case‑management practice. Understanding of injury nature, disability periods, and required treatment. Familiarity with URAC standards, ODG, utilization review, and state workers’ compensation guidelines. Knowledge of pharmaceuticals for pain management and drug rehabilitation. Knowledge of behavioral health. Excellent oral and written communication, including presentation skills. Proficient with Microsoft Office and other PC software. Leadership, management, and motivational skills. Analytic and interpretive abilities. Strong organizational skills. Excellent interpersonal and negotiation skills. Team‑work capability. Ability to meet or exceed performance competencies. Work Environment Consideration for reasonable accommodations will be given when applicable. Physical: Computer keyboarding. Auditory/visual: Hearing, vision, and speaking. Expected salary range: $87,600.00‑$97,000.00. What We Offer Competitive compensation and career advancement opportunities. Benefits include medical and dental plans, life insurance (eligible spouse and children), health‑care flexible spending, dependent care, 401(k) savings plans, and paid time off. We strive to create an inclusive culture where all employees are appreciated and respected. Our commitment to diversity encompasses race, ethnicity, gender, sexual orientation, culture, religion, and disabilities. #J-18808-Ljbffr