Evergreen Nephrology
Healthcare
RNNavigator-CKD
Neural analysis suggests this role is
optimal for Mid candidates.
“RN Navigator - CKD at Evergreen Nephrology. Skills: Care coordination, Patient education, Disease progression monitoring. Enroll and engage patients. Assess care gaps”
What You'll Achieve.
Optimize patient outcomes; Promote self-management; Ensure seamless transitions of care; Identify care gaps; Navigate the patient through their CKD to ESKD journey; Help patients achieve their goals; Timely and proactive care planning; Planned outpatient dialysis start with a permanent access; Care pathway of the patient’s choice; Close quality gaps; Prevent disease progression; Improve patient outcomes; Improve quality of life; Delay disease progression; Shift care to the home; Accelerate kidney transplants
Industry & Context.
Critical thinking
Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps, Cable, Fiber, or DSL connections hardwired to the internet device are recommended, Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
What They're Looking For.
Must Have
Registered Nurse (RN) with active state licensure, 5 years of experience, 3 years in nephrology, dialysis, transplant coordination, or chronic disease management, Experience with team-based care, Excellent working knowledge of community resources, Exceptional capacity to multitask, Self-directed, Comfort with ambiguity, Communication skills, Teaching skills, Intermediate skills with MS Office Suite of products including Outlook and Teams, Able to work effectively in a primarily remote environment, Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps, Cable, Fiber, or DSL connections hardwired to the internet device are recommended, Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Nice to Have
Bachelor of Science in Nursing (BSN)
What You'll Do.
Enroll and engage patients
Coordinate care to close quality gaps
Facilitate smooth transitions of care
Develop and implement care plans
Coordinate referrals for transplant evaluation
Coordinate dialysis access placement
Coordinate home dialysis training
Ensure timely follow-up of lab results
Ensure timely follow-up of imaging studies
Ensure timely follow-up of provider visits
Assist with early dialysis access planning
Interpret and trend laboratory values
Recognize and escalate signs of worsening kidney function
Provide evidence-based interventions
Identify barriers to care
Connect patients with appropriate resources
Guide patients in understanding health services
Guide patients in understanding social services
Serve as primary point of contact
Address patient concerns
Facilitate communication between healthcare providers
Provide emotional support
Provide counseling to patients
Maintain open lines of communication
Ensure accurate and timely documentation
Provide comprehensive education to patients
Provide comprehensive education to families
Empower patients in self-management
Educate patients on CKD-safe medications
Educate patients on avoiding nephrotoxic drugs
Educate patients on managing polypharmacy
Conduct individualized educational sessions
Conduct group educational sessions
How You'll Work.
Team & Collaboration
Collaborate with the Nephrologist team to establish trust and relationships with patients; Collaborate with interdisciplinary team and Nephrologist to develop and implement care plans; Collaborate with vascular surgeons and nephrologists for early dialysis access planning; Maintain open lines of communication with patients, families, caregivers, and healthcare teams
Communication Scope
Communication skills
Full Job Description
Who You Are You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change. Who We Are Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants. We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today. Your Role The CKD RN Navigator is responsible for providing care coordination, education, and support to patients with chronic kidney disease (CKD) across various stages of the disease. This role serves as a liaison between patients, families, nephrologists, primary care providers, and the interdisciplinary healthcare team to optimize patient outcomes, promote self-management, and ensure seamless transitions of care. Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse
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