Transplant Nurse II

Elevance Health•Tampa, FL

1d•Remote

About The Position

The Transplant Nurse II provides case and/or medical management for members receiving transplant services. The nurse takes on increasing assignments in preparation for advancement to the senior level. Within the scope of licensure, the role assesses, develops, implements, coordinates, monitors, and evaluates care plans to optimize member health across the care continuum and ensure access to services suited to members’ needs. The role is primarily virtual, with required in-person training sessions. Candidates must be within a reasonable commuting distance of the posting location(s), unless an accommodation is granted as required by law. The schedule is day shift and includes both Saturday and Sunday.

Requirements

Associate degree in nursing and at least 3 years of clinical experience, or an equivalent combination of education and experience.
Current unrestricted RN license in applicable state(s).
Ability to obtain licensure in multiple states in a timely manner.

Nice To Haves

Bachelor’s degree or higher in a health-related field.
Certification as a care manager.
Knowledge of the medical management process and ability to interpret and apply member contracts, benefits, and managed care products, especially for associates performing medical management.
Knowledge of health insurance and benefits.

Responsibilities

Assess individual needs and establish care management plans with objectives and goals.
Implement care plans by facilitating authorizations and referrals within the benefits structure or through extra-contractual arrangements.
Coordinate internal and external resources to meet identified needs.
Monitor and evaluate care plan effectiveness and make modifications as needed.
Interface with Medical Directors and Physician Advisors on care management treatment plans.
Help resolve provider, claims, or service issues.
Assist with developing utilization and care management policies and procedures.
Collaborate with healthcare providers and members on complex transplant issues to promote quality outcomes, optimize benefits, and use resources effectively.
Assess medical necessity for inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and treatment settings, applying medical policy and industry standards and interpreting benefits and managed care products.
Conduct pre-certification, retrospective, out-of-network, and treatment-setting appropriateness reviews for compliance with criteria, medical policy, member eligibility, benefits, and contracts.
Ensure access to medically necessary, quality healthcare in a cost-effective setting according to contract.
Consult clinical reviewers and/or medical directors to support medically appropriate, high-quality, cost-effective care throughout medical management.
Collaborate with providers to assess members’ needs and support early identification and proactive discharge planning.
Facilitate care transitions across the healthcare continuum and refer treatment plans or plans of care to clinical reviewers as required; do not issue non-certifications.
Support accreditation by understanding, interpreting, and applying accrediting and regulatory requirements and standards.