• Provides care management support to a panel of patients who require specialty services integrated and in support of their overall plan of care. • Interacts with and supports the specialty care providers, primary care providers and the interdisciplinary care team across the continuum of care. • Assesses, plans, implements, documents, coordinates, monitors, evaluates, and updates the plan of care by collaborating with all members of the health care team to provide evidenced-based care. • Works to establish collaborative processes that promote quality and cost-effective care that optimizes the physical and psychosocial health of patients. • Responsible for supporting decisions that impact health care outcomes, resource allocation and customer experience. • Engages in quality improvement initiatives and program development.

• Engaging daily with clients and teammates to build and sustain positive relationships • Monitoring device readings and managing inbound calls • Assessing patient alerts and determining response requirements • Entering patient information into appropriate systems • Explaining products or services and answering client questions • Assisting with enrollment of new clients and supporting existing clients • Troubleshooting devices and reporting malfunctions • Participating in other projects or duties as assigned

• Conducting educational telephone calls advising members of available benefits, services and programs; completes health needs assessment, and refers members to population health management programs as appropriate. • Reaching out to members with identified gaps in care; encouraging and motivating them to become compliant; offering assistance in locating providers and appointment scheduling. • Managing system work queues; screening identified members for eligibility, prior case activities, recent claims, customer service inquiries and authorization history; assigning members to clinical team for call outreach and intervention. • Facilitating research and analysis of inquiries and/or complaints related to processes and designations, member lost incentives, and other program related inquiries. • Work overtime as needed • Various immunizations and/or associated medical tests may be required for this position.

• 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.