UM Nurse, Transplant RN (Remote)

Date: Sep 2, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5696 

 

Position Summary/Position

 

Under the general direction of the Clinical Director or Utilization Manager, the Utilization Management Nurse, Transplant RN, in conjunction with Care Management, is responsible for the coordination and management of services for Members with complex Transplant needs. The Utilization Management Nurse, Transplant RN will act as a liaison between the facilities and work directly with the member and provider to ensure the member is assisted through all phases of the Transplant process covered by IEHP.

Major Functions (Duties and Responsibilities)

 

1. Liaison between all Transplant COEs and IEHP.  Develops and maintain a working relationship with all Centers of Excellence.
2. Generates & ensures communication of authorizations to the referring provider, COE, member & claims unit. Collaborates with the Transplant Center Coordinator and providers to ensure that the process fulfills all regulatory requirements.
3. Access to Clinical Services: Anticipates delay in processes & works to ensure members' timely access to required consultations/diagnostic procedures requested by COE. Coordinates appointments for consultations or diagnostics with providers & members according to the medical indication.
4. Reduces redundancy & costs by collaborating with the Transplant Center coordinator to maximize repatriation of services whenever it is clinical appropriate & within the confines of the member’s contract with the Health Plan.
5. The UM Transplant Nurse will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet the member's transplant and health needs.
6. Collaborate with the Care Manager to ensure Care Plan is updated, additional health needs are being addressed, and other Care Management needs are completed timely.
7. Responsible for the oversight and/or performance of authorization of other, outpatient  or ancillary services as per approved clinical criteria, including but not limited to, outpatient surgery, durable medical equipment, home health, etc. within regulatory timeframes.
8. Serves as a resource for IEHP Member and Provider Service departments for outpatient utilization management, referral, and continuity of care issues for members with Transplant, ESRD, or other complex needs.
9. Responsible for timely and appropriate documentation in the medical management system.
10. Responsible for identifying potential cases for Case Management, Disease Management, , Health Education and/or quality of care issues and making appropriate referrals when needed.
11. Responsible for identifying alternate payer sources such as CCS, IRC, etc.
12. Responsible for working with Team Members to support the goals of the department and the vision of the organization.

Experience Qualifications

 

3 - 5 years of clinical experience in a health care delivery setting. 

Preferred Experience

 

Experience in an HMO or experience in Managed Care setting preferred. Experience with Transplant and UNOS preferred.

Education Qualifications

 

High school diploma or GED required.

Professional Licenses

 

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement

 

Knowledge of outside agencies and resources such as, CCS, IRC, IHSS, Medicare, etc. Knowledge of capitated managed care environment helpful. MediCal, Medicare and other state/federal Program & Regulations.

Skills Requirement

 

Excellent communication and interpersonal skills, strong organizational skills. Microcomputer skills, proficiency in Windows applications preferred.

Abilities Requirement

 

Ability to build relationships. Professional demeanor.

Commitment to Team Culture

 

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

 

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

 

Starting Salary: $75,296.00  - $95,992.00  

Pay rate will commensurate with experience

 

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

 


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles