- Provide comprehensive healthcare in-person and via telehealth across co-morbid chronic conditions common to CKD/ESKD patients
- Support complex patients in navigating the healthcare system
- Deliver holistic, integrated care to improve kidney patients’ quality of life
- Function autonomously while collaborating with the healthcare team
- Provide, coordinate, and facilitate quality, cost-effective care
- Perform enhanced annual wellness visits or Comprehensive Health Evaluations (CHEs)
- Identify and evaluate patients’ co-morbid conditions and medical, social, emotional, and financial needs
- Manage complex patients with a focus on reducing hospitalizations and improving health outcomes
- Manage CKD/ESKD patients to delay disease progression and reduce medical costs, utilization, and hospitalizations
- Conduct proactive post-discharge planning and follow-up with high‑risk patients
- Use prescriptive authority, medication management, and ordering/interpretation of labs and diagnostics
- Coordinate activities with healthcare teams and healthcare systems
- Work Monday–Friday with a flexible, self‑managed schedule accommodating patient and nephrology partner availability
- Travel within an assigned geography, including dialysis clinics and nephrology practices
Requirements
- Must live locally in Minneapolis/St Paul, MN
- Minimum of two (2) years' experience as a Nurse Practitioner (NP)
- Current unrestricted NP license to practice in the state of CT
- License in NY or ability to get after hire
- Current Drug Enforcement Administration (DEA) license required or eligible to obtain within 90 days of hire
- Current Cardiopulmonary Resuscitation (CPR) or Basic Life Support (BLS) certification
- Current valid driver’s license and insurance within the state of residence
- Intermediate computer skills and proficiency in MS Word, Excel & Outlook required
- Demonstrated proficiency in clinical assessment and management of complex comorbidities, diagnosis, planning, implementation, documentation, and evaluation regarding the needs and care of chronic disease
- Strong clinical judgment and confidence in autonomous decision-making while practicing within established protocols and evidence-based guidelines
- Home Office, High Speed Internet and Reliable Transportation Required
- Preferred experience working in Value Based Care or Population Health, including documenting and coding from a MA (Medicare Advantage) risk perspective and conducting Health Risk Assessments on high risk/chronically ill patients
- 5+ years’ experience as a Family Nurse Practitioner (FNP), Primary Care Nurse Practitioner (NP), or experience in Internal Medicine, Cardiology, Nephrology or Case Management
- Prior experience with Cerner or similar EHR system
Core Competencies
Demonstrates expertise in managing CKD/ESKD patients through comprehensive healthcare delivery, including telehealth and in-person visits, while effectively coordinating with healthcare teams. Proficient in clinical assessment, medication management, and navigating complex healthcare systems to improve patient outcomes.
Highest-signal resume keywords
- Nurse Practitioner (NP) License
- Clinical Assessment and Management
- Medication Management
- Value Based Care Experience
- Cerner EHR Proficiency
ATS Optimization Keywords
Hard Skills
- Chronic Disease Management
- Comprehensive Health Evaluations (CHEs)
- Patient Navigation
- Autonomous Decision-Making
- Health Risk Assessments
- Documentation and Coding
- Enhanced Annual Wellness Visits
- Co-Morbid Condition Evaluation
- Post-Discharge Planning
- Cost-Effective Care Coordination
Soft Skills
- Strong Clinical Judgment
- Collaboration with Healthcare Teams
- Effective Communication
- Problem-Solving
- Patient-Centered Care
Certifications & Qualifications
- Current NP License
- Current DEA License
- Current CPR Certification
- Current BLS Certification
Industry Keywords
- CKD
- ESKD
- Value Based Care
- Population Health
- Medicare Advantage (MA)
- Chronic Conditions
- Healthcare System Navigation
- Nephrology
- Internal Medicine
- Case Management
Tools & Technologies
- MS Word
- MS Excel
- MS Outlook
- Telehealth Platforms
- Healthcare Systems Coordination