Care Coordination RN (Path to Supervisor)
About The Position
The Care Coordination RN provides clinical and operational support for Kidney Specialists of Minnesota’s expanding Value-Based Care initiatives. Reporting to the Nursing Manager, the role is the primary clinical resource for the CKD Stage 2–5 Chronic Care Management (CCM) program and supports Renal Care Coordination (RCC) clinical tasks, including CMS Form 2728 validation and chart reviews, dialysis access and dialysis initiation referrals, and transitional care management visits for patients with ESRD. The position is intended to develop toward a formal Care Coordination Lead or Supervisor role as program enrollment grows and RCC workflows stabilize; supervisory readiness is evaluated at 6–12 months. The RN partners with Care Managers to deliver clinical engagement, create comprehensive care plans, and conduct monthly patient touchpoints. The role owns day-to-day clinical CCM workflows, supports non-RN Care Managers with complex patient needs, medication reconciliation, and symptom management, and contributes to RCC chart auditing and workflow development. The RN also provides clinic nursing coverage, telephone triage overflow support, and mentorship to Care Managers and clinical support staff.
Requirements
- Active Registered Nurse (RN) license with the Board of Nursing in both Minnesota and Wisconsin.
- Minimum 2–3 years of clinical nursing experience in nephrology, outpatient dialysis, or clinical care management.
- Familiarity with ESRD documentation, specifically CMS Form 2728, CKD staging, and care plan development.
- Proficiency with EMR systems for chart reviewing and workqueue tracking.
Nice To Haves
- BSN preferred.
- Experience with Acumen and/or Epic preferred.
Responsibilities
- Partner with Care Managers to drive day-to-day clinical engagement, comprehensive care plan creation, and monthly touchpoints for CKD Stage 2–5 CCM patients.
- Take ownership of clinical CCM workflows and support day-to-day program execution.
- Serve as a clinical escalation point for non-RN Care Managers on complex patient needs, medication reconciliation, and symptom management.
- Review, audit, and track completion of CMS Form 2728 forms to support optimal dialysis starts and regulatory compliance.
- Conduct targeted Acumen/Epic chart reviews for modality transitions, hospital discharge follow-ups, and specialty referral completions.
- Provide front-line feedback to the Nursing Manager and Systems Operations to refine and standardize RCC workflows.
- Support routine RN coverage, including referral management, lab review and follow-up, prescription enrollments and refills, and prior authorizations.
- Assist with telephone triage when the primary triage nurse team is overwhelmed or understaffed.
- Support onboarding, clinical growth, and daily guidance of Care Managers and clinical support staff.
- Help monitor program metrics and patient enrollment targets while building operational capabilities for a potential supervisory role.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
