Duo Health·Tolleson, Arizona
The Nurse Practitioner will assume primary medical responsibilities for a designated small panel of patients with CKD stages 3b-5 and ESRD, delivering patient-centered care through in-home visits, teleconferences, and phone consultations. This involves developing individualized care plans addressing both medical and psychosocial needs in collaboration with a multidisciplinary team.
This role is based in West Valley, Arizona area and involves a mix of on-location responsibilities and remote work. Company Mission Duo Health is a new type of medical group designed around the needs of patients with chronic kidney disease (CKD) and their physicians. Our unique Health Mobilization™ platform partners multidisciplinary care teams with community nephrologists and activates all the other clinicians, facilities, and community organizations necessary to treat the whole patient on their terms. Our team consists of leaders in value-based healthcare, technology, and behavioral science, all sharing a vision of advancing health equity, one relationship at a time. Our interprofessional care teams, including physicians, nurses, social workers, and patient navigators, provide high-touch and comprehensive care to a small panel of patients. Team collaboration is essential to our intensive psycho-social model of care, which includes assessment, medication management, social management, and behavioral health management.
As a Nurse Practitioner at Duo Health, you will be an integral part of a collaborative care team, providing high-quality, value-based care to a panel of patients with CKD stages 3b, 4, 5, and End-Stage Renal Disease (ESRD). In this role, you will interact directly with patients through in-home visits, teleconferences, and phone consultations, ensuring they receive personalized and coordinated care. You will work closely with both patients and care team members to foster strong relationships and create individualized care plans. Each day will involve ongoing communication with the care team and patients to ensure optimal care coordination and positive health outcomes.
Assume primary medical responsibilities for a designated small panel of patients with CKD stages 3b-5 and ESRD, delivering patient-centered care and driving clinical outcomes.
Conduct comprehensive patient assessments, including history and physical exams, and order diagnostic tests as necessary.
Develop and implement individualized care plans addressing both medical and psychosocial needs in collaboration with the care team.
Educate patients and their caregivers on medical conditions, treatment options, medication management, and lifestyle adjustments to improve health outcomes.
Collaborate daily with a multidisciplinary team of healthcare professionals, including Nephrologists, Nurses, Social Workers, and Patient Navigators, to provide coordinated care.
Participate in regular care team meetings to discuss patient progress, challenges, and care adjustments.
Foster strong relationships with patients, their families, and the care team to ensure seamless care delivery and positive experiences.
Facilitate patient care across various settings, including home health visits, dialysis clinics, hospitals, skilled nursing facilities, and community-based organizations.
Identify the need for specialty consultations (e.g., medical, surgical, psychiatric) and coordinate referrals as appropriate.
Provide after-hours telephonic support for patients, ensuring continuity of care outside normal hours as needed.
Maintain accurate, timely, and detailed documentation for all patient encounters, adhering to company policies and regulatory requirements.
Contribute to the development and implementation of clinical care guidelines to enhance patient outcomes.
Participate in continuous quality improvement initiatives to optimize care delivery and patient satisfaction.
Candidates must possess an active Arizona Advanced Practice Nurse (APN) License, meet credentialing standards, and have reliable transportation for travel within the West Valley area. Experience managing chronic conditions like CKD or ESRD and bilingual skills in Spanish are preferred.
Market context
Nurse practitioner roles in Arizona with home-visit duties are often competitive because they require active APN licensure, credentialing clearance, and the flexibility to travel across the service area. This position stands out for its patient-home coverage in Yuma County, so candidates should be ready to show a reliable vehicle, a clean driving record, and comfort working independently. Requirements and benefits here are AI-summarized from the original job description, helping you review the role faster; confirm your Arizona APN license and travel readiness before applying.
