RN Care Manager, Optimal Starts

What You’ll Do 

The Registered Nurse Care Manager, Optimal Starts is responsible for the management of CKD Stage 4/5 patients who are at risk to require kidney replacement therapy (Optimal Starts) by providing education on CKD management and modality options, and by facilitating access placement and a stable transition to kidney replacement therapy.  Works alongside Strive nurse practitioners and the nephrology care team to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. Acts as resource for patients and their families, the local care team, and other healthcare professionals. Services to patients may be provided virtually or telephonically, and in-person through on-site visits to clinics, medical offices, hospitals, or patient homes.   

The Day to Day 

• Collaborates with the nephrology care team to develop an individualized and comprehensive education plan for the patient  
• Provides education telephonically, virtually, and in-person in clinics, medical offices, hospitals or patient homes
• Provides appropriate education, support, and materials to facilitate informed decision making and understanding of chronic kidney disease management and modality options
• Provides updates to care team and family members. Identifies patient knowledge and understanding deficits and adjusts the education plan to address
• Coordinates referrals to transplant centers and facilitates the completion of the transplant work-up process
• Revises and adjusts the patient care plan to reflect educational needs of the patient
• Participates in the PAM (Patient Activation Measure) process including, but not limited to, administration of the PAM survey and working with patients on improvement of PAM score
• Proactively contacts the patient on a frequent basis as specified in the program details to assess their situation, provide assistance, and answer questions as necessary 
• 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
• Collaborates with Network Engagement and Clinical Leadership teams to prepare for and participate in clinical review meetings with external Nephrology Practice focused on CKD stage 4/5 and ESRD patients 
• 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 
• Provides in-person patient care which may include standing, sitting, walking, pushing, pulling, and lifting. 

 

Minimum Qualifications 

• Associate’s degree from accredited school of nursing.
• Current state-specific RN licensure to practice, with additional licensure required to meet regional needs
• 3+ years’ experience in renal nursing
• 1+ year experience providing patient education
• Current BLS certification required. 
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms.
• Efficient and reliable transportation, including an active driver’s license, allowing for the ability to travel across an assigned region to meet patient needs. Locations may include offices, clinics, and patient homes.   

 

Preferred Qualifications 

• Excels at developing strong patient and family relationships that fosters engagement and best outcomes for all aspects of Strive Health’s Model of Care 
• Certification in nephrology nursing or patient education preferred
• Experience in dialysis home modalities or transplantation preferred
• Demonstrated knowledge and understanding of data and managing to clinical, financial, and patient satisfaction outcomes  
• Demonstrated experience and effectiveness in a change agent role
• Basic computer skills and proficiency in MS Word and Outlook required 

 

Annual Salary Range: $79,000.00-$94,000.00