RN Case Manager - Care Ally - Nephrology

RN Case Manager - Care Ally - Nephrology

1 day ago Be among the first 25 applicants

Full‑time, 40 hours per week. Monday through Friday, 8:00 a.m. to 5:00 p.m.; flexibility to work later as needed. Hybrid work arrangement.

• 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.
• 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.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.

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 work 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.

• 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 services; inventory & 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; elevate 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…