Coordinates comprehensive care and case management for nephrology patients using an interdisciplinary approach. Facilitates patient dispositions, monitors care plans, and serves as a liaison between patients, families, and medical providers.
Requirements summary
Requires a Bachelor's degree in Nursing or a related field, or 3 years of case management experience, plus 2 years of renal care experience. Must obtain a Registered Nurse License (California) and a Dialysis or Nephrology Nurse Certificate within 24 months of hire.
In addition to the responsibilities listed below, this position is also responsible for supporting case management services for nephrology patients to ensure quality of care using an interdisciplinary approach; assisting others with creating population-based reports on outcomes specific to nephrology patients; helping team members collaborate between nephrology patients, families, community resources, and medical staff/providers; making post disposition follow-up calls to all patients who are not referred to an ambulatory case/care management program using specific instructions and guidance; and assisting in facilitating a smooth transfer to home or an alternate facility, and acting as a contact person for dispositions while resolving standard issues.
Essential Responsibilities
Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members. Listens to, addresses, and seeks performance feedback. Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work. Assesses and responds to the needs of others to support a business outcome. Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies, and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship. Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
Assists in providing services related to the initial case assessment by: coordinating with patients and their families to evaluate needs, goals, and current services with day-to-day supervision; determining initial eligibility, benefits, and education for all admissions with day-to-day supervision; entering authorization data (e.g., authorization data regarding admitting/principle diagnoses, bed type(s), and disposition data for accuracy, after visit summary) with general guidance; supporting others in exploring options to assure that quality, cost-efficient care is provided; and leveraging working knowledge to assess medical necessity for hospital admission and required level of care to inform physicians.
Assists in monitoring and evaluating plan of care by: coordinating resources and services to assure continuity and quality of care; supporting the review and updating of authorizations, attending case management rounds with clinicians, and reviewing diagnoses as needed; contacting patients periodically to assess progress toward treatment milestones and care plan goals with day-to-day supervision; assisting with identifying barriers to achieving goals and ensuring that they are discussed with the patient and care team thoroughly; assisting with verifying that all services remain consistent with established guidelines and standards; and documenting/updating the patients case in all medical files with minimal guidance.
Assists in providing services related to the case-planning process by: partnering in the development of a client-focused case management plan with treatment goals based on the patients and familys/caregivers needs under limited guidance; collaborating with health-care team, patient, and caregivers to assure plan of care is safe, agreeable, and appropriate with guidance; and validating that the plan is consistent with regulatory, accreditation, and regional guidelines with some guidance. Supports efforts to remain updated on current research, policies, and procedures by: coordinating with others to attend seminars, workshops, and approved educational programs and workshops specific to professional needs; contributing to the implementation of systems, processes, and methods to maintain team knowledge of community resources, with some guidance; analyzing operational team data and key metrics applied to own work with limited guidance; making suggestions for change or improvement as needed with minimal guidance; and learning about and adhering to policies and regulations impacting the teams work with minimal guidance.
Assists in services related to patient disposition by: assisting in identifying patients ready for disposition planning activities under guidance; beginning to develop, evaluate, coordinate, and communicate a comprehensive disposition plan in collaboration with the patient, family, physician, nurses, social services, and other healthcare providers and agencies; and obtaining authorizations/approvals as needed for services for the patient with day-to-day supervision.
Assists in connecting patients with existing services by: supporting patients with gaining access to care based on their needs and integrating or referring them into existing programs/services with minimal guidance; referring patients to outside entities, ambulatory case managers, care managers, social workers, and/or internal/external resources as appropriate with guidance; and gathering and summarizing information for making location-specific adaptations as necessary. Assists others in serving as liaison between internal and external care by: reviewing benefits/services available based on regulations or specific coverage to patients, families, and other members of the community, and assisting with problem solving identified concerns with general supervision; providing case management to a limited caseload of low-risk patients referred to external facilities/agencies with general supervision; learning and applying standard strategies and concepts to propose recommendations in interdisciplinary team meetings with internal and/or external stakeholders with guidance; and leveraging working knowledge of the patients case to act as a resource for physicians, health plan administrators, and contracted vendors.
Minimum Qualifications
Minimum two (2) years of renal care, kidney education, end-stage renal disease (ESRD), dialysis modalities education, or coordination of dialysis experience. Bachelors degree in Nursing or related field OR Minimum three (3) years of experience in case management or a directly related field. Dialysis Nurse Certificate within 24 months of hire OR Nephrology Nurse Certificate within 24 months of hire Registered Nurse License (California) within 24 months of hire
