Transplant Nurse II

This is a fully remote position, open to applicants in Florida, +3 more states.

📋 Description

• Deliver case and/or medical management for members utilizing transplant services

• Evaluate individual requirements and formulate tailored care management strategies

• Execute care plans by facilitating necessary authorizations and referrals

• Coordinate both internal and external resources to address identified needs

• Oversee and assess care management plans, making adjustments as necessary

• Collaborate with Medical Directors and Physician Advisors regarding treatment plans

• Aid in resolving provider, claims, and service-related issues

• Support the formulation of utilization and care management policies and procedures

• Work in partnership with healthcare providers and members to enhance quality outcomes and optimize resource use

• Evaluate the medical necessity of admissions, services, procedures, out-of-network services, and treatment environments

• Perform pre-certification, retrospective, out-of-network, and treatment-setting appropriateness evaluations

• Ensure access to essential, high-quality, cost-effective healthcare

• Consult with clinical reviewers and medical directors throughout the medical management process

• Collaborate with providers to identify early and engage in proactive discharge planning

• Facilitate member care transitions and refer care plans to clinical reviewers when necessary

• Support accreditation by adhering to accrediting and regulatory standards and requirements

• Pursue continuous learning and undertake increasing peer-role responsibilities in preparation for advancement to a senior position

⛳️ Requirements

• Associate's degree in nursing with a minimum of 3 years of clinical experience; or a combination of education and experience providing a comparable background

• Current unrestricted RN license in the relevant state(s) is mandatory

• Bachelor's degree or higher in a health-related discipline or certification as a care manager is preferred

• Strong knowledge of the medical management process and the ability to interpret and apply member contracts, benefits, and managed care products is highly preferred for medical management associates

• Must be capable of obtaining licensure in multiple states promptly

• Solid understanding of health insurance and benefits is strongly preferred

• Demonstrated strong clinical acumen

• Familiarity with oncology/hematology or stem cell and organ transplant is preferred

• Candidates should reside within a reasonable commuting distance from the job location unless an accommodation has been granted

• Candidates in specific patient/member-facing roles must be vaccinated against COVID-19 and Influenza, unless a valid exemption is provided

• Availability Monday–Friday, from 8:00 AM to 4:30 PM EST

• Preference for candidates who can work in applicable Eastern and Central time zone locations

🏝️ Benefits

• Extensive benefits package

• Performance-based salary increases

• Paid holidays

• Paid Time Off

• Incentive bonus programs

• Medical insurance offerings

• Dental insurance offerings

• Vision insurance offerings

• Short-term disability insurance

• Long-term disability insurance

• 401(k) plan with company match

• Stock purchase program

• Life insurance coverage

• Wellness initiatives

• Financial literacy resources

• Mandatory in-person training sessions for virtual associates

• Incentive and recognition programs

• Equity stock purchase options