Transplant Nurse II
Core
Provides case and medical management for members receiving transplant services, assessing needs, developing care plans, and ensuring cost-effective, medically appropriate care.
Role type
Licensed Nurse (Case & Medical Management)
Builds
Care management plans and utilization review decisions for transplant members
Domain
Healthcare / Health Insurance / Managed Care
Deliverable
dashboards & analysis
Required skills
Nursing assessment, care plan development, authorization/referral facilitation, resource coordination, medical necessity review, benefits interpretation, regulatory compliance
Preferred skills
Care management certification, medical management process knowledge, multi-state licensure, health insurance/benefits knowledge
Technologies
Managed care products, utilization review systems
Responsibilities
Conduct assessments to identify individual needs and develop care management plans; Implement care plans by facilitating authorizations and referrals; Coordinate internal and external resources to meet identified needs; Monitor and evaluate effectiveness of care plans; Review pre-certification, retrospective, and out-of-network services for medical necessity and compliance; Consult with clinical reviewers and medical directors on treatment plans; Facilitate member care transitions and discharge planning.
Seniority
Mid-level IC