Transplant Nurse Advisor

This is a fully remote position, open to applicants in United States.

📋 Description

• Operates under general supervision to manage transplant needs for individuals covered by the applicable transplant benefit contract.

• Assists in the continuous development of transplant medical policies.

• Provides review support to Underwriting and Claims for evaluating risk.

• Manages all intake and initial case setup for new transplant patient referrals.

• Performs due diligence to identify potential preexisting conditions for new referrals.

• Engages with referral sources, patients, attending physicians, hospitals, and transplant teams to gather necessary information for coverage determinations and quoting transplant benefits.

• Facilitates the review of medical information by the Medical Director to ascertain medical necessity and whether treatments are experimental or investigational under the relevant transplant benefit contract.

• Maintains ongoing communication with patients, transplant teams, and referral sources throughout the transplant benefit period.

• Assists in gaining access to transplant network centers.

• Evaluates, plans, facilitates, and coordinates care delivery for transplant patients.

• Provides initial and ongoing education regarding transplantation to patients.

• Monitors the health status of patients and their compliance with treatment plans throughout the transplant benefit period.

• Conducts concurrent reviews while patients are hospitalized for transplant-related services.

• Initiates discharge planning and assesses medical necessity for home health care and/or skilled nursing requirements.

• Coordinates transplant-related medical appointments and facilitates referrals to community resources as needed.

• Communicates with the non-transplant benefit administrator when non-transplant services are identified.

• Documents all transplant case management activities in the patient record within the excess database.

• Keeps abreast of current transplant technology and advancements.

• Aids in the formulation of transplant clinical guidelines and medical policies.

• Evaluates disclosed potential transplant candidates and assesses future risk in support of the transplant underwriting process.

• Reviews claims to distinguish between transplant and non-transplant related services as required.

• Updates the database with all clinical contacts from transplant centers.

• Travels as requested (minimal).

• Performs other relevant duties and/or special projects as assigned.

⛳️ Requirements

• Bachelor's Degree in Nursing, a related field, or equivalent education and/or experience.

• A minimum of 5 years of relevant and progressive professional nursing experience in Case Management, ideally in Transplant Case Management.

• Preferred experience in clinical transplant program management and/or oncology nursing.

• Experience in Transplant Medical Policy is a plus.

• Must hold an active, current, and unrestricted state Registered Nurse (RN) License.

• Extensive knowledge of disease states, their progression, and management, particularly end-stage organ/tissue diseases and their treatments.

• Strong communication skills, capable of engaging assertively, effectively, and collaboratively with management, staff, hospitals, physicians, and patients.

• Demonstrated ability to apply a broad understanding of principles, practices, and procedures.

• Excellent written and verbal communication skills, emphasizing confidentiality, tact, and diplomacy.

• Exceptional organizational and analytical abilities, with a proven track record of managing multiple tasks simultaneously.

• Familiarity with industry changes, legal updates, and technical developments relevant to the Company's business to proactively respond to a dynamic business environment.

• Intermediate proficiency and experience with the Microsoft Office suite (Excel, Access, PowerPoint, Word).

🏝️ Benefits

• Comprehensive medical, vision, and dental coverage, with eligibility starting on your first day of employment.

• Basic life and disability insurance.

• 401(k) plan with a 6% company match.

• 20 days of paid time off (PTO), two floating holidays, approximately 11 paid holidays, and volunteer time off.

• Paid parental leave.

• Access to our award-winning wellness program, which includes mental health services, a fitness network membership, and a complimentary Headspace subscription.

• Student loan matching program.

• Employee discount program.

• An opportunity to engage in meaningful work and find fulfillment in your role.