Transplant Nurse Advisor
Help us insure it
Tokio Marine HCC is a global industry-leading specialty insurance group, backed by the strength and stability of the Tokio Marine Group. Offering over 100 classes of specialty insurance, we empower clients to pursue opportunities confidently through our “Mind Over Risk” philosophy. More than an insurance company, we are an organization built on innovation, unity, and trust.
At our core, we are Always Advancing, driven by innovation and an entrepreneurial spirit that keeps us moving forward. Our people are Experts in Tomorrow, using curiosity and smart working to anticipate what’s next. With a culture rooted in Reaching Out, we foster genuine collaboration and support, ensuring every individual has the opportunity to succeed and make a difference.
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
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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