RN Case Manager - Care Ally- Nephrology

RN Case Manager - Care Ally - Nephrology - Hybrid Opportunity

• Full-Time, 40 hours per week. Monday through Friday, 8:00 a.m. to 5:00 p.m.; flexibility to work later as needed

Benefits: 

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year. 
• Immediate 401(k) match.
• 40 hours paid volunteer time off. 
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

The Nephrology RN Care Manager is a critical member of our integrated specialty care team consisting of nurses, dietitians, pharmacists, care coordinators, and physicians. The Nephrology RN Care Manager will be working in collaboration with the specialty care team, healthcare professionals, patients, and families to provide ongoing support and communication for patients with complex chronic kidney disease (CKD) and End-Stage Renal Disease (ESRD). The primary focus of the role will be to improve patient outcomes, including delaying disease progression, avoiding unnecessary inpatient and emergency department utilization, improving medication adherence, helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, and educating patients on self-management. The role is integral to our specialty care team and will focus on advanced clinical support through clinical triage, care plan development, and high-risk care management. In addition, the Nephrology RN Care Manager will assess and coordinate resources available to patients and maximize the use of health care benefits.

The Nephrology RN Care Manager will be supported by predictive data to identify the highest risk CKD and ESRD patients and high-touch care workflows that integrates with Duly’s primary and specialty care providers. While primarily conducted via telecommunication, this role may necessitate on-site visits to various healthcare clinics or dialysis centers. This position will also serve as the clinical escalation point for non-RN Care Coordinators, supporting continuity and collaboration across the care team.

• Enroll and manage a case load of patients with high-risk CKD and ESRD medical needs
• Knowledge of CKD and ESRD stages and disease progression, including associated co-morbid conditions
• Conduct comprehensive clinical assessments via phone, including medical, behavioral, pharmaceutical, and social needs of the patients per policies and procedures.
• Maintain proactive communication with Nephrologists, PCP offices and other clinical partners to ensure timely clinical escalation, alignment with treatment plans, and coordination of servicesInventory and reconcile medications and coordinate with pharmacists and prescribers; encourage medication and treatment adherence through frequent contact with patients
• Assess home safety and social determinants of health (SDOH) barriers, including transportation, food insecurity, housing instability, and caregiver support; escalate resources where appropriate.
• Perform patient health assessments and surveys as required
• Facilitate care across the continuum of care, spanning settings such as the home, hospital, and skilled nursing facilities
• Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions
• Deliver education on CKD, ESRD, dialysis and associated comorbidities; Assess the patient’s knowledge of their renal condition and provide education and self-management support
• Serve as the initial point of contact for escalations and provide clinical oversight to Care Coordinators, including delegation of tasks as appropriate
• Review and document patient updates and progress
• Coordinate with dialysis providers to ensure transitions of care are seamless
• Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities
• Analyze data collected from the predictive modeling tools to identify eligible patients for care management
• Proficient in knowledge of current Case Management Standards
• Assist with the evaluation and amendment of Case Management Policy and Procedures
• Review and act on population health dashboards to address care gaps (annual wellness visits, lack of symptom monitoring, missing labs, etc)

• 2+ years previous experience working in care management and/or with CKD/ESRD patients
• Organization: Able to provide order and structure to daily processes and work environment. Demonstrates good organizational skills and ability to prioritize daily work.
• Strong analytical and critical thinking skills. Strong community engagement and facilitation skills
• Effective in identifying and analyzing problems. Proactively acts as a patient advocate and responds with resolve.
• Excellent verbal communication: Capable of interacting with, and relating to, people of varying educational levels and backgrounds, conveying information clearly and succinctly, applying listening, tact, responsiveness, empathy, and confidentiality. Effective in communicating verbally with other staff and departments related to the job responsibilities.
• Core values consistent with a patient-centered approach to care. Ability to show empathy and quickly build relationships with patients and physicians
• Team Work: Must be able to get along with others, work as part of a team, accept constructive criticism, adapt behaviors quickly, and consistently follow and apply work rules. Works effectively with others to accomplish objectives and goals. Willingly offers assistance to others when the need arises. Fosters teamwork and positive rapport within all departments to maximize achievement of goals.
• Computer Proficiency: Must be able to type 40 wpm on a keyboard-typing test required. Proficient in Microsoft Office and mobile phone and web-based applications
• Ability to show empathy and quickly build relationships with patients and physiciansCurrent
• Registered Nurse License in the State of Illinois
• Certified Case Manager (CCM) certification preferred.
• Current Basic Life Support (BLS) certification is required in this role.
• 2+ years previous experience working in care management and/or with CKD/ESRD patients.
• Prior experience interacting with patients primarily via telecommunication
• 3+ years combined of related education, experience, or certification.
• Management experience preferred

   

The compensation for this role includes a base pay range of $79,040-104,000, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.