Accelerating health equity one patient at a time by providing no-cost, high-quality kidney and heart care to eligible members

We are looking for a Registered Nurse Care Manager to join our team

Responsibilities

Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health; The RN Care Manager is expected to conduct approximately 12 assessments per week and manage a panel of about 150 assessed patients.
Based on this assessment, and in conjunction with the patient, patient’s nephrologist & PCP, and other members of the care team, create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient;
Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s);
Facilitate care across the continuum of care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility;
Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions;
Assess the patient’s knowledge of their renal condition and provide education and self-management support;
Provide ongoing reassessment and follow-up to improve patient outcomes.

Qualifications

Required

1+ years of nursing experience in case management or care management, preferably coordinating care across multiple settings.
2+ years healthcare related experience.
Current, unrestricted compact Registered Nurse license
Requires all teammates to maintain current, valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider.
Core values consistent with a patient-centered approach to care
Proactively acts as a patient advocate and responds with resolve.
Knowledge and experience to empower patients in self-management and shared decision making
Enjoys working collaboratively with team members.
Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.