Transplant Nurse II

Transplant Nurse II

Shift: Monday Friday, 8:00am 4:30pm EST

Location: Virtual, Eastern and Central time zone locations preferred. Alternate locations may be considered if candidates reside within a commuting distance from an office

Virtual: 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.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law

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 will 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.

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.
• Must have strong clinical acumen.
• Knowledge of oncology/hematology or stem cell and organ transplant is preferred.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $75,680.00 to $119,196.00

Locations: Columbus, OH; New York

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

*The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, paid time off, stock, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.