Role Overview
Under general supervision, manages covered individual transplant needs related to the applicable transplant benefit contract. Provides support in the ongoing development of transplant medical policy. Provides review support to Underwriting and Claims for risk assessment.
Key Responsibilities
- Perform all intake and initial case set-up for new transplant patient referrals.
- Conduct due diligence for potential preexisting conditions on new referrals.
- Communicate with referral source, patient, attending physician, hospital, and transplant team to obtain necessary information for coverage determination as well as quote transplant benefits.
- Facilitate review of medical information by Medical Director for medical necessity and experimental/investigational determination under the applicable transplant benefit contract.
- Perform all written communications to patients, physicians, transplant programs, and hospitals.
- Maintain regular contact with patient, transplant team, and referral source as applicable throughout the transplant benefit period.
- Facilitate access to transplant network centers.
- Assess, plan, facilitate, and coordinate the delivery of care for transplant patients.
- Provide initial and ongoing education about transplantation to the patient.
- Monitor patient health status and compliance to treatment plan throughout transplant benefit period.
- Conduct concurrent review while patient hospitalized for transplant related services.
- Initiate discharge planning as well as medical necessity for home health care and/or skilled nursing needs.
- Coordinate transplant related medical appointments and make necessary community resource referrals.
- Communicate with underlying non-transplant benefit administrator when non-transplant services are identified.
- Document all activities related to transplant case management in the patient record in the excess database.
- Maintain knowledge base of current transplant technology and advances.
- Assist in writing transplant clinical guidelines and medical policy.
- Review disclosed potential transplant candidates and assess for future risk in support of the transplant underwriting process.
- Review claims to determine transplant versus non-transplant related services as needed.
- Keep database updated on all transplant center clinical contacts.
- Travel as requested (minimal).
- Other relevant duties and/or special projects as requested.
What You Bring
- 4 Year / Bachelors Degree Nursing, a related field, or the equivalent education and/or experience
- 5 Years relevant and progressive professional nursing experience in Case Management, preferably in Transplant Case Management.
Clinical transplant program management and/or oncology nursing experience preferred
Experience in Transplant Medical Policy a plus. - Active, current, and unrestricted state Registered Nurse (RN) License
- Experience in Transplant Medical Policy a plus.
- Broad knowledge base in disease states, progression and management, especially end-stage organ/tissue diseases and their treatment
- Ability to communicate assertively, effectively, and collaboratively with management, staff, hospitals, physicians, and patients
- Possess and have ability to apply broad knowledge of principles, practices, and procedures
- Excellent written and verbal communications skills with an emphasis on confidentiality, tact, and diplomacy
- Exceptional organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously
- Knowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company's business to proactively respond to changing business environment
- Intermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word)
Additional Working Conditions and Physical Demands- Overtime hours may be required to fulfill job responsibilities
- May be required to remain stationary for extended periods of time
- May be required to move up to 10 pounds
- Must be able to operate a computer and other devices
- Close vision and ability to adjust focus, such as required to read a computer screen
What We Offer
- Competitive salary and comprehensive benefit package
- Strong learning culture with ongoing development opportunities
- Opportunities for growth and career advancement
- Comprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employment
- Basic life and disability insurance
- 401(k) plan with 6% company match
- 20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off
- Paid parental leave
- Access to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscription
- Student loan matching program
- Employee discount program
- An opportunity to do meaningful work and love what you do
The pay range for this position is
$63,400-$140,000, which includes geographic adjustments, where applicable. The pay range is the range THMCC, in good faith, believes is the range of compensation for this role at the time of this posting. The hired applicant will be offered pay within the entire range based on the candidate's geographic location, qualifications, work experience, education, and/or skill level. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of color, race, sex, national origin, sexual orientation, religion, age, veteran status, disability, pregnancy, citizenship status, genetic information, or any other basis protected by federal, state, or local pay equity laws.
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