RN Case Manager - Care Ally - Nephrology

Duly Health and Care•Downers Grove, IL

18d•$79,040 - $104,000•Hybrid

About The Position

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.

Requirements

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
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.

Nice To Haves

Certified Case Manager (CCM) certification preferred.
Management experience preferred

Responsibilities

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)

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.

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