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Registered Nurses are needed for a dynamic, fast-paced start-upwith an innovative care management position that is transforming the delivery of kidney care. You will be driving to patients' homes who suffer from chronic kidney disease. We are looking for someone who works well with ambiguity, drive time, and telehealth components. Most patients are suffering fromchronic kidney disease (CKD) and end-stage renal disease (ESRD).
Lots of driving! This position will cover a two-hour travel radius.
Rare domestic travel may be required to headquarters in Nashville, TN
Ability to occasionally visit patients or take calls remotely on some nights and weekends
Work with Microsoft Office and mobile phone and web-based applications
Perform in-home care management visits to assess and impact the social and behavioral status
Work closely with Care Team to ensure continual progress on all care management goals
Coordinate with dialysis providers to ensure transitions of care are seamless
Create and administer care plans, rather than rendering direct clinical services
Perform medical assessments and deliver individual, family, and group education on living with chronic illness, dialysis, and associated comorbidities
Engage family and social support groups in the education and care of patients
Assess patients and refer them to behavioral health specialists for diagnosis and treatment Help patients to understand accept and follow medical and lifestyle recommendations
Serve as the point of contact for patient questions regarding social and behavioral
Facilitate conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities, and AV fistula placement
Initiate patient relationships through enrollment and onboarding processes
Document patient updates and progress in the care management platform
Identify, vet and build relationships with local Community-Based Organizations
Introduce patients to appropriate resources and act as the patient advocate
Serve as subject matter expert on social determinants for other members of the Care Team
Help prevent costly and traumatic episodes such as avoidable hospitalizations, readmissions, and unexpected kidney failure