Elevance Health - Nashville, TN
posted about 13 hours ago
Full-time - Mid Level
Hybrid - Nashville, TN
Insurance Carriers and Related Activities
About the position
The Transplant Nurse II is responsible for providing case management and/or medical management (UM/UR) for members receiving transplant services. Within the case management role and 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. Learn and take on increasing work assignments for the peer role on the team in preparation for advancement to the senior level.
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 as necessary.
- 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.
- 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 through assessing the medical necessity of inpatient admissions, outpatient services, focused 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.
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
- Willing and able to be licensed in multiple states (compact license), in a timely manner, at the company's expense.
- Previous dedicated transplant experience is very strongly preferred.
- Previous ICU, Med/Surg, and ER experience is extremely helpful for this position.
- Both Case Management and/or Medical Management (UM/UR) is highly desired.
- Ability to interpret and apply member contracts, member benefits, and managed care products preferred.
- Certification as a Case Manager is preferred.
- Previous work from home/remote experience is very beneficial for this position.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short and long term disability benefits
- 401(k) + match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
