Transplant Nurse II

Transplant Nurse II

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Work Schedule: Day shift; will include weekends (both Saturday and Sunday).

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, within the scope of licensure will 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.

How you will make an impact:

• 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.
• 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.

Minimum 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.

Preferred Skills, Capabilities and Experiences:

• 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.

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.