RN Transplant Case Mgr II 4 Locations

Anticipated End Date:

Position Title:

Job Description:

LOCATION: This is a remote position and you must be within 50 miles/1-hour commute of an eligible PulsePoint location.

HOURS: Monday through Friday, 11:30 am - 8:00 pm, EST. Training is provided during regular business hours, 8:30 am - 5:00 pm.

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.

Primary duties may include, but are not limited to:

• 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.

Required Qualifications

• 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 Qualifications

• You must be 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.

• Within the medical management process, the 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.

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Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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 may contact elevancehealthjobssupport@elevancehealth.com for assistance. 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.