Assess members in the home or other face-to-face setting to assess the member’s wellbeing and develop an individual plan of care 

Evaluate the home environment for safety, infection control, and community resource needs 

Act as first level of support for the member to resolve patient related issues to ensure a positive member experience  

Identify opportunities to manage the member-centric care plan, problems, barriers, interventions, and goals as appropriate 

Partner with the Healthmap Interdisciplinary Care Team to collaborate on opportunities to improve member’s health outcomes 

Serve as a resource to members and physicians while acting as a liaison between community resources, programs, and other relevant services 

Educate Healthmap members on kidney health, related co-morbid conditions, and renal replacement therapy   

Drive and shape clinical strategy to improve outcomes for members with chronic kidney disease 

Document and maintain accurate member records that will identify all patient communication and plan. Maintain thorough documentation of all provider meetings/interactions and member interactions for consistency and coordination and compliance with regulatory standards Ensure company adherence with legal and regulatory requirements 

Assist as a preceptor, mentor, and coach for new hire orientees 

Demonstrate HIPAA understanding and complete confidentiality protocols 

Follow all company-defined security/operational policies and procedures 

Use multiple technical applications including Microsoft Word, Excel spreadsheets, electronic calendars, email, timekeeping and expense applications, and other software applications 

Perform other duties as assigned 

Master’s degree in nursing required

3 years of experience in care management roles 

Experience in a nephrology practice, dialysis center, home health delivery or transplant center preferred 

Prior experience building and managing relationships with health care providers or patients preferred 

Experience in customer service strongly preferred     

Experience with Medicare and Medicaid preferred  

Proof of valid and unrestricted driver’s license required. This position requires travel within assigned region to visit patients in their homes

Assigned state residency required 

Excellent verbal, written, listening and presentation skills

Ability to show compassion and empathy for patients

Demonstrated interpersonal relationship skills  

Ability to multitask, prioritize, and create solutions in a fast-paced environment

Strong critical thinking and analytical skills  

Must be proficient in Microsoft Office: Outlook, Word, Excel, PowerPoint