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The RCC organizes the care and follow up for late-stage CKD patients to maintain health, prolong the timeframe and ensure a planned transition into Renal Replacement Therapy (RRT). Services provided focus on educating patients holistically in all areas affecting the kidney: diet, exercise, medication adherence, and treatment modalities. The RCC works as part of an interdisciplinary team to provide patient care which will continue from identification of the patient as part of a value-based care program through a smooth transition to RRT if needed / selected.

• Partner with appropriate teams, including providers and staff, to provide, coordinate and integrate modality education, coordinate placement and maintenance of permanent dialysis access, and reduce the incidence of non-optimal starts to RRT.
• Provide holistic education to CKD patients to support maintenance of health and delayed progression of kidney disease.
• Interact with appropriate staff to ensure each patient and family member (if applicable) receives information on specific modality advantages and disadvantages, as well as education on hemodialysis access types.
• Identify and address patient financial and insurance resources and concerns.
• Ensure NKP’s late-stage CKD patients receive CKD education, have a permanent access placed when possible prior to RRT, and make a stable transition to RRT.
• Utilize EHR to provide reports and analyze trends, anomalies, and areas of concern to improve the care of late-stage CKD patients.
• Empower late-stage CKD patients to select the appropriate modality and, if possible, to secure and maintain a permanent dialysis access prior to starting RRT.
• Provide support, guidance, and coordination of care for patients from late-stage CKD to selection of RRT, conservative care, and/or transplantation. For patients selecting RRT, continue to coordinate care as needed after dialysis initiation to ensure a smooth transition.
• Communicate with other members of the CKD patient’s Care Team, including the PCP, vascular and PD surgeons, and others, to improve patient health, care, and outcomes.
• Provide regular in person and/or telephonic interventions to patients.
• Assist NKP in complying with value-based care requirements for its late-stage CKD patients, including participation in any surveys or other reporting requirements.
• Participate in meetings to review the RCC program within the practice and to review pertinent RCC data. Participate in other meetings as requested by the leadership team.
• Escalate issues to supervisor/manager for resolution.
• Review and comply with all applicable company policies and procedures, local, state and federal laws and regulations.
• Assist with various projects as assigned by direct supervisor.
• Perform other duties as assigned.

• 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, 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.

Bachelor's Degree or an equivalent combination of education and experience

• 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 with 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.
• 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 and possesses 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.