Clinical Review Nurse

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

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.

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.