Transplant Nurse II

Elevance Health•Tampa, FL

7d•Remote

About The Position

The Transplant Nurse II provides case and/or medical management for members receiving transplant services. The role involves continuing to learn and taking on increasing assignments in preparation for advancement to the senior level. Within the case management scope of licensure, the nurse assesses, develops, implements, coordinates, monitors, and evaluates care plans to optimize member health across the care continuum and ensure access to services appropriate to members’ health needs. Within the medical management role, the nurse collaborates with healthcare providers and members on complex transplant issues to promote quality outcomes, optimize benefits, and use resources effectively. The position ensures medically appropriate, high-quality, cost-effective care by assessing medical necessity, applying medical policy and industry standards, interpreting benefits and managed care products, and directing members to appropriate providers, programs, or community resources. The role also supports compliance with accreditation and regulatory requirements.

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, or certification as a care manager.
Knowledge of the medical management process and ability to interpret and apply member contracts, benefits, and managed care products, particularly for medical management work.
Knowledge of health insurance and benefits.

Responsibilities

Conduct assessments to identify individual needs and develop care management plans with objectives and goals.
Implement care plans by facilitating authorizations and referrals within benefit structures or through extra-contractual arrangements.
Coordinate internal and external resources to meet identified needs.
Monitor and evaluate care management plan effectiveness and modify plans as needed.
Interface with Medical Directors and Physician Advisors to develop care management treatment plans.
Assist in problem solving with providers, claims, or service issues.
Assist with development of utilization and care management policies and procedures.
Collaborate with healthcare providers and members on complex medical 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 appropriateness of treatment settings.
Apply medical policy and industry standards, interpret benefits and managed care products, and direct members to appropriate providers, programs, or community resources.
Conduct pre-certification, retrospective, out-of-network, and treatment-setting appropriateness reviews to ensure compliance with criteria, medical policy, eligibility, benefits, and contracts.
Ensure members have access to medically necessary, quality healthcare in a cost-effective setting according to contract.
Consult with clinical reviewers and/or medical directors to support appropriate, high-quality, cost-effective care throughout the medical management process.
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; does not issue non-certifications.
Support accreditation by understanding, interpreting, and applying accrediting and regulatory requirements and standards.