Seeking a dynamic, innovative, collaborative professional who embraces commitment to superior service and quality. AmTrust Financial Services, an industry-leading insurance provider and top writer of workers' compensation insurance, has a need for a Quality Assurance Specialist in medical case management oversight for workers' compensation within i n our Managed Care Organization. The position may be located in one of our offices - Princeton, NJ, Maitland, FL, Alpharetta, GA, Chicago, IL, Dallas, TX, Irvine, CA, or alternative locations.
PRIMARY PURPOSE: The Quality Assurance Specialist will provide comprehensive and quality oversight activities in line with the organization's quality and medical case management standards. This position will report to the Director of Medical Education and Strategy within the Managed Care Organization. Focus for role with development and execution of the Quality Assurance Programs for both internal medical case management and external case management to align with AmTrust's philosophy for holistic, injured employee centric approach to achieve best in class outcomes for claims. These responsibilities may include review of utilization review programs, pharmacy program clinical oversight, home health and all care coordination for claims in addition to identification and analysis of trends to provide recommendations for the overall program to further enhance and improve.
- Carry out quality assurance oversight activities defined in the AmTrust Medical Case Management and Quality Assurance Standards.
- Conduct regular and systematic review of Managed Care internal and external medical case management files with focus towards validation of comprehensive case assessments, evaluations and proactive strategies developed and executed to address medical and disability management, treatment and pharmacological plans to ensure evidence based medicine is evaluated consistently.
- Reviews to also focus towards completion of activities and case management goals are in a timely manner, have appropriate follow ups, appointments are made within recommended frequency, ensure there are no gaps in service and medical care coordination.
- Analysis of Quality Assurance reporting metrics to identify strengths, trending and provide recommendations which can support and tie into educational training development needs for the overall programs.
- Measure and identify staffing competency levels from quality assurance reviews.
- Track, monitor, and measure quarterly and annual performance of the programs.
- Present reports, findings, and recommendations for enhancements and/or changes based on analysis to the Managed Care Leadership and Workers' Compensation leadership teams on both internal and external case management programs.
- Work with managed care leadership and nurses to calibrate quality standards across all offices.
- Review and conduct evaluation of external case management programs to ensure service level agreements, and performance measures are met and/or exceeded.
- Conduct billing and financial audits for external strategic partners to ensure compliance with contracted financial agreements.
- Act as liaison with external and internal strategic partners to manage overall quality measures of the case management program.
- Other duties may be assigned.
Education and Licensing
Active unrestricted RN license in a state or territory of the United States with eligibility to get and/or renew a multistate license req uired. Bachelor's degree in nursing (BSN) from an accredited college or university or equivalent work experience or equivalent work experience preferred. Certification in case management, rehabilitation nursing or a related specialty is required (CCM, COHN, CRRN, etc.). Quality Assurance program designations such as Health Care Quality and Management certification (HCQM) highly preferred. Acquisition and maintenance of insurance license(s) may be required to comply with state requirements.
Minimum five (5) years of related experience required to include two (2) years of direct clinical care, and two (2) years of case management and minimum of one (1) year in quality assurance role is required. Prior analytical experience with data and reporting outcomes in managed care setting is required. Understanding and prior experience with URAC accreditation and utilization review programs is required.
Preferred previous clinical experience emergency room, critical care, home care or rehabilitation experience.
Skills and Knowledge Requirements:
Knowledge of workers' compensation laws and regulations
Knowledge of case management practice
Knowledge of the nature and extent of injuries, periods of disability, and treatment needed
Knowledge of URAC standards, ODG, Utilization review, state workers compensation guidelines
Knowledge of pharmaceuticals to treat pain, pain management process, drug rehabilitation
Knowledge of behavioral health
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Analytic and interpretive skills
Strong organizational skills
Excellent interpersonal and negotiation skills
Ability to work in a team environment
Ability to meet or exceed Performance Competencies
When applicable and appropriate, consideration will be given to reasonable accommodations.
Position schedule is normal business hours Monday through Friday
Required travel: 10-15% - Travel is required for training, onboarding and as the business needs dictate.
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
Hearing, vision and talking 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.
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