PURPOSE AND SCOPE:

Promotes quality patient care, ongoing patient support and case management for Fresenius Medical Care (FMCNA) renal patient population (internal and external) by providing guidance, support, care coordination, education and other case management functions as defined by the pertinent program. Manages the implementation of the pertinent program as assigned while acting as the subject matter expert and resource for patients, dialysis staff, physicians and other healthcare professionals. Services are generally provided telephonically but there may be programs where on-site visits to clinics, medical office, hospital are required.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Utilizes nursing knowledge and judgement, data analysis, time management skills, review of medical information, collaboration with clinical and non-clinical members of the healthcare team, and knowledge of clinical processes to develop and facilitate coordination of care for value-based program patients via telephonic support.
• Leads the assessment of patient conditions, in conjunction with clinic staff, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention. Utilizes good documentation practices to accurately document interactions with members, members' health records, caregivers, and other stakeholders. Maintains and updates the appropriate software/tracking logs of patients in the program to manage and record required information and data. Generates and analyzes reports as needed for management, identifying trends, anomalies, and areas of concern.
• Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program.
• Adheres to company, department, program policies and clinical guidelines to identify, review, assess and allocate patients for program participation according to their identified needs.
• Acts as a representative of the Nursing and Clinical Services department in collaborating with the FMCNA Medical Office and with the clinical staff, physicians, and other members of the patient's healthcare team, to develop an individualized and comprehensive plan of care according to the applicable program specifications.
• Leads and ensures the coordination and integration of services as planned in the pertinent program while revising the plan as needed to provide high quality continuity of services and cost-effective service delivery.
• Utilizes motivational interviewing techniques to influence members to engage in their own care.
• Builds collaborative, productive relationships with teammates, members, and other stakeholders.
• Participates in process improvement activities.
• Self-manages worktime to ensure completion of assigned work during scheduled shifts.
• Adheres to scheduled shifts, being "in your seat" at scheduled time and prepared to begin work. Communicates proactively to direct supervisor any deviations from scheduled shifts.
• Maintains current and accurate nursing knowledge and best practice guidelines, including specifics regarding chronic kidney disease and end-stage renal disease.
• Evaluates program processes and makes recommendations to management that will improve the effectiveness and efficiency of the program.
• Acts within state's RN Scope of Practice in all situations.
• Maintains the integrity of Protected Health Information (PHI).
• Complies with all departmental required data collection and auditing activities.
• Participates in quality improvement activities and project-based work as instructed by direct supervisor.
• Improves job-related capabilities through continuing education, professional seminars, and technical workshops.
• Collaborates with providers and dialysis clinics to identify and mitigate hospitalization and mortality risk for members.
• May refer to senior level staff for assistance with higher level problems that may arise.
• Escalates issues to supervisor/manager for resolution, as deemed necessary.
• Performs other related duties as assigned.
  
  Imminent Hospitalization Predictive Model
• Coordinates routine outreach tailored to meet each patient needs to address their patient populations just in time care.
• Acquires and Maintains licensure as assigned.
• Provides coordination and patient outreach for specific target patient populations.
• Ensures the delivery of effective, efficient, integrated and evidenced based services and interventions that include physical, behavioral, and social objectives.
• Utilizes clinical judgment, independent analysis, critical thinking skills, and time management skills.
• Utilizes telephonic and other technical and electronic communication formats to remotely monitor the care of the patient according to the program requirements.
• Contacts the patient and/or clinic on as needed basis as specified in the program details to assess their situation, provide assistance, and answers questions as necessary.
• Communicates effectively with patients, FKC facility staff, and physicians regarding patient issues to ensure that all issues are addressed and resolved.
• Calls to clinic are based on urgent patient needs.
• Reviews and analyzes facility-specific and patient-specific reports.
• Engages third party translation services as indicated to carry out patient education.
• Assures adherence to all HIPAA regulatory requirements, including, but not limited to telephonic conversations.
• Assures adherence with all work at home

SUPERVISION:

• None

EDUCATION AND REQUIRED CREDENTIALS:

• Bachelor's Degree Preferred
• Active, unrestricted, compact-state RN license required
• Certified Case Manager (CCM) preferred
• Certification in nephrology specialty (CNN, CDN) a plus

EXPERIENCE AND SKILLS:

• 2 – 5 years’ bedside nursing experience required. Dialysis nursing experience preferred but not required.
• Must exhibit excellent communication skills and be able to collaborate via telephonic interaction with both clinical and non- clinical
• team members to facilitate desired care coordination outcome.
• Well-developed motivational interviewing techniques.
• Excellent verbal and written skills.
• Excellent analytical skills.
• Proficient in word processing, spreadsheet, and email applications.
• Proven ability to be a team player.

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.