Community Based Advanced Practice Provider Cincinnati

Job Summary:

This community-based role focuses on identifying, staging, and longitudinally managing members with chronic kidney disease (CKD) across

Absolute

Care'sattributed population. The CKD CBP partners with in-home extenders (paramedics, RNs, LPNs) who perform initial assessments and specimen collection, then conducts facilitated telehealth and face-to-face visits to diagnose CKD, optimize guideline-directed medical therapy (SGLT2 inhibitors, RAAS inhibitors), coordinate nephrology referrals, and prepare members for renal replacement therapy when indicated. Working in partnership with the member's primary care provider, interdisciplinary care team, and virtual nephrology consultants, the CKD CBP ensures smooth transitions of care post-hospitalization, closes medication and diagnostic gaps, and supports members in slowing disease progression through whole-person, value-based care.

• Perform enrollment and longitudinal visits (telehealth and face-to-face) with members suspected or confirmed
  
  CKD.

• Conduct clinical assessments, diagnose and stage CKD per KDIGO guidelines (eGFR + albuminuria), and enroll members in the appropriate CKDcare pathway.

• Initiate andoptimizeguideline-directed medical therapy — SGLT2 inhibitors, RAAS inhibitors, nonsteroidal MRAs — in conjunction with the member's PCP or independently if no PCP is established.

• Ensure renal-adjusted medication dosing;identifyanddiscontinuenephrotoxic agents.

• Refer to nephrology or other specialists in coordination with the member's primary care team.

• Provide CKD stage-appropriate education: dietary modifications, exercise, disease progression, and self-management.

• Provide community-basedmedicalandcare-coordinationservicesforrecentlydischarged members.

• Partner with the transitional care manager and PCP to execute the discharge plan, perform medication reconciliation, andidentifybarriers to safe transition.

• Deliver member and family education; gather critical information from the home environment and communicate findings to the care team.

• Initiate "Strong Start" pathway activities for members with eGFR