000200 - Nurse - Registered Nurse

Registered Nurse provides nursing interventions to nephrology practice patients that participate in value-based care programs. The RN will manage a caseload of patients as they navigate the staged progression of chronic kidney disease (CKD). This will be done during acute and post-acute episodic interventions, including condition assessment, SNF coordination, education, etc. in the patient’s home and virtually. Collaborating with Care Team and physicians to prevent readmission, prevent future hospitalization, and improve patient care. RNs will further engage patients considered high risk for advancing CKD progression and unplanned dialysis starts, in one-on-one, in-person, or remote encounters to provide focused education, self-management strategy reinforcement, medical management, linkage to appropriate resources, and other core nursing needs. The goals of this 50% remote 50% in-person position are to empower the CKD and ESRD patient to be more involved in their own care and focus on medical risk factors to improve outcomes related to disease progression, reduction of hospitalizations, and unplanned dialysis starts.  Responsibilities include: Manage a caseload of nephrology practice patients and perform clinical needs assessments/complex-medical management for high-risk CKD/ESRD patients. Collaborate with Care Team and physicians to prevent readmission, prevent future hospitalization, and improve patient care. Weekly home visits and or remote engagements with patient’s post-discharge from hospitalization, in coordination with LCSW’s, to address any complex medical and psychosocial needs. Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education, and identify post-hospital needs. Routine remote engagements and home visits with patients with an unplanned ‘crash’ start to dialysis. Will assess and assist patients for linkage and utilization of appropriate community resources in conjunction with other members of the care coordination team. Maintain clinical notes for each patient receiving care and provide progress updates to nephrologist and care team as appropriate. Provide high intensity engagement with patient and family. Introduce self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance, and education. Enhance a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions. Refers cases to social worker for complex psychosocial and economic needs. Kidney Disease Education (KDE) for all nephrology practice patients taught in coordination with Registered Dietitians and LCSW’s. Act as a patient’s advocate, liaison, and information resource and escalating all appropriate, critical information to their nephrologist in a timely manner. Complete timely and accurate documentation per company policy and any relevant professional and regulatory standards. Facilitate projects and presentations designed to develop and improve the role of the RN case manager in the value- based care programs. Act as resource and representative for value-based care at health fairs and professional seminars as assigned. Assists with coverage for PTO and open positions as requested. Serves as a preceptor when assigned. Perform other duties and responsibilities as required, assigned, or requested. Qualifications: Degree in Nursing from an accredited institution. Active, unencumbered clinical level of licensure in the state of practice. Active and unsanctioned driver's license. Minimum of 5 years of experience working in the healthcare industry. Minimum of 2 years of experience working with the chronically ill (CKD/ESRD preferred). Home care, case management, and/or hospital experience preferred. Requires working knowledge of Microsoft Office products. Requires experience with medical records documentation. Knowledge of, and experience with, electronic medical records systems. High level of comfort communicating with patients and team members through virtual platforms such as Zoom and Microsoft Teams.