RN Renal Care Coordinator

Job ID 21000GY3

Available Openings 1

PURPOSE AND SCOPE:

Organizes the care and follow up for late stage CKD patients to ensure a planned transition into Renal Replacement Therapy (RRT). Focuses on improving the preparation of late stage CKD patients who need to start RRT by ensuring each patient receives treatment modality education and receives the most suitable permanent access, while minimizing the use of temporary catheters. The Renal Care Coordinator ensures every late stage CKD patient receives appropriate coordination of care in order to begin RRT at the facility designated by the Nephrology Practice and the patient.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

  • Partners with appropriate teams, including providers and FMC-NA staff, to provide, coordinate and integrate Kidney Care:365 (KC-365) modality education, to coordinate placement and maintenance of a permanent dialysis access and to reduce the incidence of non-optimal starts to RRT. Activities include the following:
    • Liaisons with appropriate staff to ensure every patient and family member (if applicable) receives comprehensive information on specific modality advantages and disadvantages, hemodialysis treatments both at home and in-center, peritoneal dialysis, kidney transplantation and conservative care, as well as education on hemodialysis access types with focus on the health and safety benefits of AV Fistula or AV-Graft compared to central venous catheters.
    • Identifies and addresses patient financial and insurance resources and concerns as needed.
    • Organizes the Nephrology Practice late stage CKD patient population with regard to CKD education, including modality selection, permanent access placement and maintenance and a stable transition to RRT.
    • Utilizes appropriate EHR, to develop and maintain a HIPAA compliant database of information about late stage CKD patients in the program providing reports and analyses, identifying trends, anomalies and areas of concern. Participates in the interpretation of summary clinical data and its use in improving late stage CKD care processes.
    • Participates in the complex decision-making of modality selection and the creation and maintenance of a permanent dialysis access for patients starting RRT.
    • Assesses patients' knowledge of late stage CKD and treatments, educating and informing patients to enable them to make informed decisions regarding the steps to manage health issues during the transition to RRT.
    • Provides support, guidance and coordination of care for patients seeking conservative care or palliative care.
  • Participates with appropriate staff and teams to facilitate community• focused education initiatives for Primary Care Physicians (PCPs) such as the following:
    • Delivers educational programs designed to build greater awareness in the local medical community of the importance of timely referral of CKD patients for nephrology care by PCP in order to reduce the incidence of acute ESRD onset without the benefit of such care and to improve management of co-morbid diseases for patients starting RRT.
    • Facilitates "face-to-face" educational meetings with community PCPs regarding different stages of kidney disease and the timelines regarding the appropriate care and actions for the particular stage in the disease.
  • Develops processes to promote communication between the Nephrology Practice and other providers such as vascular and PD surgeons to improve the care of late stage CKD patients and improve the opportunity of patients to start RRT with a permanent access.
  • Participates in the collection and analysis of clinical data that supports a dialysis outcomes tracking mechanism for all ESRD patients first day of dialysis through the first 30 days of dialysis.
  • Provides regular in person and telephonic interventions to incident patients focusing on access management, treatment adherence and barrier resolution.
  • Participates in meetings to review the RCC program within the practice and to review pertinent RCC data. Participate other meetings as requested by the CKD leadership team.
  • Escalates issues to supervisor/manager for resolution, as deemed necessary
  • Review and comply with the Code of Business Conduct and all applicable company policies and procedures, local, state and federal laws and regulations.
  • Assist with various projects as assigned by direct supervisor.
  • Performs other duties as assigned.


PHYSICAL DEMANDS AND WORKING CONDITIONS:

  • The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Day to day work includes desk and personal computer work and interaction with patients, patient families, facility staff, physicians and the community at large. The work environment is characteristic of a health care facility with air temperature control and moderate noise levels.
  • The position requires travel between facilities and various locations within the community. Travel to regional, divisional and corporate meetings may be required.


SUPERVISION:

  • None


EDUCATION:


EXPERIENCE AND REQUIRED SKILLS:

  • 2 - 5 years' previous experience in clinical patient care or case management required.
  • Proficient with computers, Microsoft Office applications and Windows operating systems.
  • A combination of hemodialysis, PD, transplantation, CKD education, case management and nutritional training highly valued.
  • Renal transplant, dialysis, or CKD patient care preferred.
  • Demonstrated knowledge of renal disease and renal transplant required.
  • Excellent written and verbal communication skills- good presentation skills.
  • Ability to communicate and maintain effective interpersonal relationships at various levels of the organization.
  • Understanding of diabetes and cardiovascular disease process and current case management practices required.
  • Good understanding of relationship between the dialysis providers and the physician practice.
  • Ability to determine when coordination may be performed by telephone or written instruction and when approval by a higher level of authority such as a physician or other health care provider is required.
  • Ability to travel with a valid driver's license.
  • Preferred experience in teaching/education and counseling in complex multi-site organization.
  • Must be highly self-motivated, dependable and organized.


EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity

Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.