Outpatient Case Manager (Renal)

Position Summary:

The Renal Care Manager Outpatient LVN is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation for high risk members with Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD). The Renal Care Manager Outpatient RN will assess and develop a care plan in collaboration with the admitting, attending physician, consulting nephrologist, the member, and other health care professionals.  

The goal of the Renal Care Manager Outpatient RN is to effectively manage CKD and ESRD members on an outpatient basis to ensure the delivery of appropriate linkage of care, prevention of avoidable in-patient admissions and re-admissions, and provision of longitudinal care, including medical, nutritional, environmental, and psycho-social needs.

Essential Duties and Responsibilities include the following:

1. Works closely with the care team to craft an outcome-based plan of care, based on the member’s input and assessed clinical and non-clinical needs of each member. Implements and evaluates the plan of care as often and as needed as evidenced by documentation in the member’s file.
2. Manages a diverse member panel, swiftly and accurately evaluating individual needs. Provides culturally sensitive care to meet the diverse needs of patients, fostering collaboration and communication among all clinical team members to enhance care provision.
3. Documents member assessment and reassessment, member care plans, and other pertinent information completed in the member’s medical record in accordance with the FOCUS Charting methodology, nursing standards, and company policies and procedures.
4. Communicates updates to the care team, the member, identifying gaps in patient understanding of their health status and delivering tailored education and resources to promote informed decision-making.
5. Acts as a liaison with dialysis centers, skilled nursing facilities, and other health providers, conveying care plan updates to facilitate smooth transitions in care, and maintains accurate records.
6. Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
7. Functions as liaison between administration, members, physicians, and other healthcare providers.
8. Generates and evaluates reports using internal data platforms to identify trends, anomalies, and areas requiring focus.
9. Performs a Clinical Assessment/Questionnaire of the member and determines an acuity score for necessary scheduled follow-up.
10. Initiates community visits (dialysis centers, hospital, and home visits) as needed to assess patient progress and meet with appropriate members of the patient care team.
11. Identifies planned and unplanned transitions of care from Requests for Services or daily inpatient and SNF census.
12. Educates the member or caregiver on the transition process and how to reduce unplanned transitions of care.
13. Manages transition of care from the sending to receiving settings ensuring that the Plan of Care moves with the member and updates the care plan as the member’s health care status changes.
14. Communicates appropriately and clearly with physicians, in patient case managers and Prior-Authorization nurses
15. Identifies and addresses psychosocial needs of the members and facilitates consultations with Social Worker, as necessary.
16. Identifies and addresses pharmacological needs of the members and facilitates consultations with the pharmacy department, as necessary.
17. Identifies and addresses nutritional needs of the members and facilitates consultations with Registered Dietitian, as necessary.
18. Identifies community resources to address needs not covered by the member’s benefit plan, and coordinates member benefits as needed, with the health plan.
19. Participates in the efficient, effective and responsible use of resources such as medical supplies and equipment.
20. Responsible for the coordination and facilitation of member and family conferences as determined by assessment of member’s needs.
21. Identifies the appropriate members to participate in the interdisciplinary case round process. Prepares the necessary summary information to present to the team.
22. Responsible for the coordination of clinic appointments, medication reconciliation, PCP and SPC visits.
23. Ability to collaborate and communicate with all members of the healthcare team (concurrent review, pre-authorization, PCP, SPC, Social Services, and Pharmacy) to coordinate the continuum of care of developing plans for management of each case.
24. Responsible for the identifying members that are appropriate for hospice conversion or Palliative care.
25. Meet with member