Transplant Nurse II (US) at Elevance Health

Florida, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Associate's degree (AS) in nursing and minimum of 3 years of clinical experience; or any combination of education and experience providing an equivalent background
Current unrestricted RN license in applicable state(s)
Must reside in Florida

Responsibilities

Conduct assessments to identify individual needs and develop specific care management plans to address objectives and goals
Implement care plans by facilitating authorizations/referrals within benefits structure or through extra-contractual arrangements
Coordinate internal and external resources to meet identified needs
Monitor and evaluate effectiveness of care management plans and modify as needed
Interface with Medical Directors and Physician Advisors on development of care management treatment plans
Assist in problem solving with providers, claims, or service issues
Assist with development of utilization/care management policies and procedures
Collaborate with healthcare providers and members to promote quality outcomes, optimize benefits, and promote effective resource use for complex medical transplant issues
Assess medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and treatment setting appropriateness using medical policy and industry standards
Conduct pre-certification, retrospective, out-of-network, and treatment setting reviews to ensure compliance with criteria, medical policy, eligibility, benefits, and contracts
Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to contract
Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care
Collaborate with providers to assess needs for early identification and proactive discharge planning
Facilitate member care transitions through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required (without issuing non-certifications)
Continue to learn and take on increasing work assignments in preparation for advancement to senior level
Facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards

Skills

Nursing

Case Management

Medical Management

Transplant Services

Care Planning

Assessments

Referrals

Authorizations

Care Coordination

Healthcare Continuum

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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