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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
• 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 preferredExperience 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.

The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC 1033(e))(the "VCCLEA"), which restricts financial institutions and insurers such as TMHCC from employing individuals with certain types of criminal convictions. Where the hiring and employment of individuals is not restricted by the foregoing, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law such as the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance, the San Diego Fair Chance Ordinance, and the San Francisco Fair Chance Ordinance.]

As an insurance company, we comply with certain federal, state and local laws such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC 1033(e)), which restricts our ability to employ individuals with certain types of criminal convictions. Where not restricted by law and for criminal history not covered by this law, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law.

You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if the Company is concerned about a conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction or challenge the accuracy of the background report. The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC 1033(e))(the "VCCLEA"), which restricts financial institutions and insurers such as TMHCC from employing individuals with certain types of criminal convictions. Where the hiring and employment of individuals is not restricted by the foregoing, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law such as the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance, the San Diego Fair Chance Ordinance, and the San Francisco Fair Chance Ordinance.]

About Us

Tokio Marine HCC is a leading specialty insurance group with offices in the United States,the United Kingdom, Europe, and other exciting locations. With the strength and stability that comes from being a member of the Tokio Marine Group, and more than fifty years of growth, profitability, and stability, we offer important insurance products that most people don't even know exist. Every policy we write is special, enabling our clients to do amazing things.

For over 50 years, HCC Life Insurance Company, operating as Tokio Marine HCC - A&H Group, has been at the forefront of medical stop loss insurance. In addition to traditional stop loss, we offer captive and Taft-Hartley stop loss solutions, level funded stop loss, Organ & Tissue Transplant insurance and MedPlus insurance. Tokio Marine HCC - A&H Group is rated A++ (Superior) by A.M. Best Company and benefits from the financial stability of its parent company, Tokio Marine HCC.

Applying our Mind Over Risk philosophy to writing insurance allows our customers to take on opportunity with confidence. That philosophy defines our way of thinking, unites us as a team, and differentiates us from our competitors. We are much more than just an insurance company; we are a good company.

Equal Opportunity Employer

TMHCC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, citizenship, color, family or medical care leave, gender identity, genetic information, marital status, medical condition, national origin, physical or mental disability, protected veteran or military status, race, ethnicity, religion, sex (including pregnancy), sexual orientation, or any other characteristic protected by applicable local laws, regulations and ordinances.

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