ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
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Works directly with the National Director of Nephrology to analyze care gaps sharing recommendations with PCPs and dialysis clinics to decrease crash into dialysis.
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Responsible for care coordination between ChenMed Nephrology team, PCPs, Dialysis units and vascular or inpatient care facilities.
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Ability to review patient charts, provide assessments and recommendations for care plan.
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Enhances home dialysis utilization for patients with emphasis on increasing de-novo start of home dialysis.
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Works with transitional care team on decreasing ESRD hospitalizations and length of stay
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Provides virtual education to patients on CKD and options for dialysis.
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Develops trusting relationships with all internal and external stakeholders to determine areas of opportunity supplemented with remediation strategies.
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Supports and completes ad-hoc initiatives including, but not limited to research and care advancement proposals.
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Ability to travel up to 75%
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Other duties as assigned.
A. Late-stage CKD (near dialysis) patients:
a. Analyze gaps in care and make recommendations to Dr Kheda/PCP
b. Nephrology and transplant referral management
c. Chart reviews and provide assessment if candidate for home dialysis’
d. Assist in development of CKD patient education material
e. Provide virtual education to patients on CKD and dialysis options
f. Care coordinate with community nephrologist to avoid ‘Crashing into Dialysis’
g. Increase de-novo start of home dialysis
h. Decrease Crash into Dialysis
B. ESRD on hemodialysis:
a. Analyze gaps in care and make recommendations to Dr Kheda/PCP/dialysis clinics
b. Do virtual assessment if candidate to transition to home dialysis
c. Care coordination with TCM team on decreasing ESRD hospitalizations and LOS
d. Care coordinate between ChenMed, Dialysis unit, vascular and inpatient care
e. Increase proportion of patients on home dialysis
f. Decrease hospitalization rate and LOS