Nephrology Care Coordinator Role
7 days ago
We are driven by a purpose: revolutionizing the kidney care system through early identification, engagement, and comprehensive coordinated care. Our high-touch care model integrates with local providers and uses predictive data to identify and support at-risk patients along their entire care journey.
About the Role:
- As a critical part of our team, you will support patient care for individuals with Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD).
- You will serve as a vital resource for patients, families, local care teams, and healthcare professionals, coordinating services to optimize care delivery.
- This hybrid role includes in-home visits based on patient requirements, with potential face-to-face meetings with colleagues and leadership as needed.
The Day-to-Day:
- You will work closely with the care team to craft personalized and thorough care plans addressing the clinical and non-clinical needs of each patient.
- Conduct regular assessments onsite and virtually to detect undisclosed medical or social issues and changes in the home environment that could pose risks, promptly referring such matters to the appropriate channels for resolution.
- You will initiate proactive outreach to patients and/or clinics as outlined in program guidelines to evaluate their status, offer assistance, and address inquiries promptly.
- Manage a diverse patient panel, swiftly and accurately evaluating individual needs while adhering to NCQA standards for complex case management.
- Communicate updates to the care team and family members, identifying gaps in patient understanding of their health status and delivering tailored education and resources to promote informed decision-making.
- Act as a liaison with dialysis facilities, conveying care plan updates to facilitate smooth transitions in care, and maintains accurate program software records.
- Generate and evaluate reports using Strive data platforms to identify trends, anomalies, and areas requiring focus.
- Provide culturally sensitive care to meet the diverse needs of Strive patients, fostering collaboration and communication among all clinical team members to enhance care provision.
- Utilize clinical judgment, analytical skills, regular and predictable attendance, and comprehensive knowledge of case management programs to deliver high-quality care.
Requirements and Qualifications:
- An Associate's degree from an accredited school of nursing is required.
- A current Registered Nurse (RN) license in the state of practice is required.
- At least 3 years of combined related education, experience, or certification is required.
- BLS or CPR Certification is required.
- Efficient and reliable transportation allowing for the ability to commute to patient's homes is required.
- Patient care may include standing, sitting, walking, pushing, pulling, and lifting.
- Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency
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