Transplant Nurse II

Elevance Health•Atlanta, NY

2d•Remote

About The Position

The Transplant Nurse II is responsible for providing case and/or medical management for members receiving transplant services. Continue to learn and take on increasing work assignments for the peer role on the team in preparation for advancement to the senior level. Within the case management role will within the scope of licensure assess, develop, implement coordinate, monitor, and evaluate care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their specific health needs. Within the medical management role will collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical transplant issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Conducts pre-certification, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medically necessary, quality healthcare in a cost effective setting according to contract. Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements

Requires AS in nursing and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in applicable state(s) required.

Nice To Haves

BA/BS or higher in a health related field or certification as a care manager preferred.
Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred for associates performing medical management.
Must be able to be licensed in multiple states in a timely basis.
Knowledge of health insurance/benefits strongly preferred

Responsibilities

Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
Coordinates internal and external resources to meet identified needs.
Monitors and evaluates effectiveness of the care management plan and modifies.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Assists in problem solving with providers, claims or service issues.
Assists with development of utilization/care management policies and procedures.
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
Conducts pre-certification, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Ensures member access to medically necessary, quality healthcare in a cost effective setting according to contract.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.