RN Navigator - CKD

Who You Are You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change. Who We Are Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants. We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today. Your Role The CKD RN Navigator is responsible for providing care coordination, education, and support to patients with chronic kidney disease (CKD) across various stages of the disease. This role serves as a liaison between patients, families, nephrologists, primary care providers, and the interdisciplinary healthcare team to optimize patient outcomes, promote self-management, and ensure seamless transitions of care. Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Care Coordinators, RN Educator, Dietitians, Pharmacists, Licensed Clinical Social Workers, and Psychiatrists. You will take the lead on identifying care gaps and navigating the patient through their CKD to ESKD journey in collaboration with a Care Coordinator, RN Educator, and the primary Nephrologist. You will play an essential role in helping patients achieve their goals through timely and proactive care planning toward a planned outpatient dialysis start with a permanent access or a care pathway of the patient’s choice driven by patient education and care team support. Role Responsibilities Patient Engagement and Enrollment: Via telephone; outreach, enroll and engage patients identified for your clinical program. Influence and collaborate with the Nephrologist team to establish trust and relationships with patients. Care Coordination & Navigation : Using clinical expertise and critical thinking, assessing care gaps in quality and supporting coordinating care to close quality gaps. Facilitate smooth transitions of care and end to end navigation for patients with CKD progressing to ESKD. Collaborate with interdisciplinary team and Nephrologist to develop and implement care plans that address the unique needs of patients, ensuring seamless transition from CKD to ESKD plan of care. Assist in coordinating referrals for transplant evaluation, dialysis access placement, and home dialysis training as needed. Ensure timely follow-up of lab results, imaging studies, and provider visits to support early intervention and prevent disease progression. Assist with early dialysis access planning (arteriovenous fistula/graft placement or peritoneal catheter insertion) in collaboration with vascular surgeons and nephrologists. Disease Progression and Monitoring: Interpret and trend laboratory values to assess CKD progression. Recognize and escalate signs of worsening kidney function, electrolyte imbalances, fluid overload, and metabolic disturbances. Provide evidence-based interventions to manage complications such as metabolic acidosis, anemia, mineral and bone disorders, and malnutrition. Social Determinants of Health: Identify barriers to care and connect patients with appropriate resources, including financial assistance programs, transportation, and community support services such as housing assistance, transportation, food security, and community support programs. Resource Navigation : Guide patients in understanding and utilizing health and social services, both within Evergreen Nephrology, other providers and through community-based organizations, to improve access to care and enhance their overall well-being. Patient Advocacy : Serve as a primary point of contact for CKD patients, addressing concerns and facilitating communication between healthcare providers. Provide emotional support and counseling to patients adjusting to CKD diagnosis and treatment plans. Collaborative Communication : Maintain open lines of communication with patients, families, caregivers, and healthcare teams to ensure coordinated care and address any issues that may arise during the care process. Documentation and Reporting : Ensure accurate and timely documentation of patient interactions, assessments, and care plans in accordance with organizational policies and regulatory requirements. Education and Empowerment : Provide comprehensive education to patients and families on CKD progression, treatment options, medication adherence, lifestyle modifications, and dialysis modalities. Empower patients to participate in self-management strategies to slow CKD progression and improve quality of life. Educate patients on CKD-safe medications, avoiding nephrotoxic drugs, and managing polypharmacy. Conduct individualized and group educational sessions on kidney health, nutrition, and disease management. Other duties consistent with this role as assigned, including cross coverage between markets when needed Required Qualifications Registered Nurse (RN) with active state licensure. Bachelor of Science in Nursing (BSN) preferred. 5 years of experience with at least 3 years in nephrology, dialysis, transplant coordination, or chronic disease management. Experience with team-based care Excellent working knowledge of community resources Exceptional capacity to multitask Self-directed Comfort with ambiguity Strong communication and teaching skills Intermediate skills with MS Office Suite of products including Outlook and Teams Able to work effectively in a primarily remote environment: Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Compensation The pay range for this role is $90,000 to $103,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors. This role is also bonus eligible. Benefits You will benefit from Evergreen Nephrology’s exceptional total rewards package, which includes: Competitive base pay with bonuses Paid time off starting at 4 weeks for full-time employees 12 paid holidays per year Medical, dental, vision and life insurance, including an HSA with employer match Reimbursement for continuing medical education 401(k) with match Paid parental leave A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws. If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at [email protected] .