RN Case Manager (Dialysis)

Job Description RN Care Manager The RN Care Manager focuses on improving the health status and care for individuals with chronic conditions and complex medical or psychosocial needs. The RN Care Manager works collaboratively with an interdisciplinary care team to identify and address gaps in care and plans, implements, and monitors individualized interventions to support patients in closing care gaps and achieving their care goals. The RN Care Manager will work to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. Acts as a resource for patients and their families, the local care team, and other healthcare professionals. Services to patients are generally provided telephonically but there may be programs where on-site visits to clinics, medical offices, hospitals or visits to patient homes are required. Essential Functions • Develops an individualized and comprehensive care plan for the patient leveraging internal and external resources. • Proactively contacts the patient and/or clinic on a frequent basis as specified in the program details to assess their situation, provides assistance, and answers questions as necessary • Revises and adjusts the patient care plan as needed to fit the needs of the patient • Monitors population health data and identifies opportunities to provide targeted patient interventions • Provides updates to care team and family members. Identifies patient and/or clinic staff knowledge and understanding deficits regarding their specific program and situation • Provides the appropriate education, support and materials to facilitate informed decision making and understanding • Assesses patient conditions, in conjunction with the care team, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention • Serves as a liaison with dialysis facilities, providing care plan updates to help streamline the transitions in care Maintains and updates the appropriate program software to manage and record required information and data • Generates and analyzes reports as needed for management, identifying trends, anomalies, and areas of concern • Adheres to company and clinical guidelines to identify, review, assess and allocate patients for program participation according to their identified needs • Participates in process improvement activities • Collaborates with all levels of the clinical team to improve processes, communication, and team skills needed to provide the best care to our patients • Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program Minimum Qualifications • BSN or MSN degree from accredited school of nursing required • Current Registered Nurse (RN) license in the state of practice required • Minimum of 5 years’ experience in clinical nursing required • Current BLS certification required. Preferred Qualifications • Excels at developing strong patient and family relationships that foster engagement and best outcomes for all aspects of Strive Health’s Model of Care • 3 years’ experience in renal, ER, ICU, Cardiac, or Ambulatory Complex case management nursing preferred • Commission for Case Manager Certification Skilled and passionate caring for patients with complex needs and is excited about the opportunity • Demonstrated knowledge and understanding of data and managing clinical, financial, and patient satisfaction outcomes • Experienced in viewing aggregated clinical data and analyzing trends • Demonstrated experience and effectiveness in a change agent role • Basic computer skills and proficiency in MS Word and Outlook required This is a hybrid role where you would do telephonic case management as well as in Home Visits for about 5 patients on average a day. A lot of travel time spent in the car driving. Pay range from 77k-mid 80;s DOE. Plus mileage and all the necessitite needed to do you job (Ipad, cell phone service, etc.) Company Description “Serving healthcare providers by connecting amazing people with exceptional employment opportunities; we commit to pursue our mission with passion, loyalty, and integrity to benefit our employees, clients, and community.”