Transplant Nurse II (US)

Elevance Health•Tampa, FL

1d•Remote

About The Position

The Transplant Nurse II role is a virtual position with the exception of required in-person training sessions. This role focuses on providing case and/or medical management for members receiving transplant services. The nurse will learn and take on increasing work assignments in preparation for advancement to a senior level. Within the case management scope, the nurse will assess, develop, implement, coordinate, monitor, and evaluate care plans to optimize member health across the care continuum and ensure access to appropriate services. In the medical management role, the nurse will collaborate with healthcare providers and members to promote quality outcomes, optimize benefits, and ensure effective resource utilization for complex medical transplant issues. This includes assessing medical necessity, ensuring compliance with criteria, and facilitating member access to medically necessary, quality healthcare in cost-effective settings. The role also involves facilitating accreditation by understanding and applying regulatory requirements.

Requirements

AS in nursing and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Requires current unrestricted RN license in applicable state(s).
Must be able to be licensed in multiple states in a timely basis.

Nice To Haves

BA/BS or higher in a health related field or certification as a care manager.
Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
Knowledge of health insurance/benefits.
Transplant experience.

Responsibilities

Conducts assessments to identify individual needs and develop a specific care management plan to address objectives and goals.
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 the effectiveness of the care management plan and modifies as needed.
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 the development of utilization/care management policies and procedures.
Collaborates with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources for complex medical transplant issues.
Ensures medically appropriate, high quality, cost-effective care by assessing medical necessity of admissions, outpatient services, surgical and diagnostic procedures, out-of-network services, and appropriateness of treatment setting.
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.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.