The Value-Based Care Management Registered Nurse interacts in-person and telephonically with chronic kidney disease patients, families, and support networks to provide comprehensive assistance in all areas related to ongoing education, medical history, medications, development of support systems, lifestyle changes and behavior modifications, thereby reducing future medical costs with early identification and support for dialysis and transplant needs.

Essential Duties and Responsibilities include the following. Other duties and tasks may be assigned.

• Responsible for the Value Base Care clinical operations activities across the continuum of care from assessing, implementing, coordinating, monitoring, and evaluating.
• Provides health education and treatment decision support for patients.
• Collaborates with the patient, patient support, and interdisciplinary team including the dialysis clinic, hospital, and physician practices in assessing the patient's needs.
• Conducts onsite in-person patient visits and outbound calls to assess patient's current health status, identifying gaps or barriers in treatment plans.
• Coordinates with and provides consultation with physicians and other health care professionals to support the quality and the level of care provided for patients affected by Chronic Kidney Disease/ End Stage Kidney Disease.
• Assists with early identification and support for dialysis and transplant needs by working closely with the Nephrologist and Value Base Care Team.
• Provides patient education to assist with self-management.
• Knowledge of and comply with federal, state, local laws, and regulations, including health care professionals practice act requirements.
• Performs duties at all times within limitations established by and in accordance with company policy and procedures, applicable state and federal laws and regulations.
• Participates in team concepts and promote a team effort; performs duties in accordance with company policies and procedures.