Value Based Care (VBC) - Nurse Case Manager San Antonio

SUMMARY

The Value-Based Care (VBC) Nurse Case Manager interacts 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. These interactions may be telephonic or in-person in USRC Dialysis Clinics, physician offices, or other locations.

• Responsible for case management activities including assessing, implementing, coordinating, monitoring, and evaluating care.
• Provides health education, coaching and treatment decision support for patients.
• Collaborates with patient, caregivers, and other healthcare providers to assess and address patient needs.
• Builds and manages close partnerships with nephrologists and dialysis team members, as appropriate, to manage care.
• Accountable for driving key metrics that improve patient outcomes and experience, including reduced hospitalizations, reduced hospital readmissions, and improve optimal dialysis starts.
• May conduct outbound calls to assess patients’ current health status, identifying gaps or barriers in treatment plans.
• May conduct in-person visits to manage patient care.
• May lead modality patient education to support optimal start milestone achievement.
• 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.
• Must be knowledgeable of and compliant 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.
• Actively promotes GUEST customer service standards; develops effective relationships at all levels of the organization.
• Participates in team concepts and promote a team effort; performs duties in accordance with company policies and procedures.
• Regular and reliable attendance is required for the job.
• May be on site working with nephrologists and other care team members up to 100% of the time.
• Position is based full-time in Texas.

• Current RN license in Texas, and additional states as contracts require. License must be maintained as current and in good standing.
• Three (3) plus years of nursing experience preferred.
• Previous experience in case management and/or providing nursing care to patients on maintenance dialysis preferred.
• Demonstrated working knowledge of the English language and ability to communicate verbally and in writing, Spanish/Bi-lingual required.
• Must have basic computer skills; proficiency in all USRC clinical applications required within 90 days of hire.
• Must meet any practice requirement(s) for the applicable state.
• Ability to meet minimum hospital/agency hiring standards which may include additional background clearances and orientation requirements if applicable to the program assigned to for employment.