RN Case Manager

Job Summary:
In the End Stage Renal Disease (ESRD)program, RN Case Managers provide comprehensive, community-based care coordination for high-need, high-risk individuals, with a focus on those with chronic conditions requiring dialysis. Leveraging clinical expertise, especially in nephrology and renal care, the RN Case Manager ensures person-centered, interdisciplinary support to help members navigate the healthcare system and improve health outcomes.

Working primarily in person and also remote, the RN Case Manager engages dialysis patients with complex medical and psychosocial needs—that include high hospital utilization, transition of care, medication reconciliation, and education on multiple co-morbidities with higher emphasis on dialysis.  This position plays a vital role in bridging gaps across acute care, dialysis treatment, social services, and long-term support systems.

Essential Duties and Responsibilities:

• Coordinate      care and provide clinical oversight for members receiving dialysis,      ensuring smooth transitions between treatment centers, primary care,      specialists, and hospital systems.
• Use      nursing judgment to assess, plan, implement, and evaluate patient-centered      care plans, integrating dialysis-specific needs.
• Educate      members on managing ESRD, dialysis adherence, nutrition, medication      compliance, vascular access care, and early signs of complications.
• Collaborate      closely with nephrologists, nurse practitioners, dialysis centers, and      interdisciplinary teams to support optimal renal care.
• Conduct      comprehensive assessments, incorporating SMART goals and motivational      interviewing techniques.
• Provide      in-person visits at dialysis centers to support member engagement and      reduce barriers to care.
• Advocate      on behalf of members to ensure timely access to renal treatment, specialty      services, durable medical equipment (DME), medications, transportation,      and other resources.
• Document      all care coordination encounters and follow-up actions in the electronic      health record (EHR).
• Track      and manage hospitalizations, discharges, missed appointments, and urgent      care visits, especially related to dialysis complications.
• Enroll      members in the ESRD program and maintain compliance with all regulatory      and programmatic guidelines.
• Provide      culturally competent, trauma-informed care in alignment with ESRD goals      and population health strategies.

Minimum Requirements:

Education:

• Current,      unrestricted Registered Nurse (RN) license in the state of practice California.
• Associate      Degree in Nursing (ADN) required; BSN preferred.

Experience:

• Minimum years of recent experience as an RN in dialysis or nephrology care      (required).
• At      least 1 year of experience in care coordination, case management, or      community health preferred.
• Experience      working with complex populations including individuals with behavioral      health needs.

Other Requirements:

• Valid      driver's license and reliable transportation.
• Proof      of current auto liability insurance per state requirements.
• Proficiency      in electronic documentation systems and Microsoft Office applications.

Preferred Skills and Competencies:

• Strong      knowledge of ESRD, CKD, dialysis modalities, and vascular access care.
• Skilled      in interdisciplinary collaboration and care team leadership.
• Excellent      verbal and written communication and clinical documentation skills.
• Demonstrated      ability to engage resistant or vulnerable populations.
• Ability      to work independently while managing a dynamic caseload.
• Bilingual      in English/Spanish.

Work Environment & Physical Demands:

• Frequent      community-based travel to dialysis clinics.
• Hybrid      schedule may include office and remote work, as applicable.
• Must      be able to lift up to 25 lbs occasionally and remain on feet for extended      periods during visits.