PURPOSE AND SCOPE:
Supports FMCNA’s mission, vision, core values and customer service philosophy. Adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements. Coordinates the care and follow up for late stage CKD patients to ensure a planned transition into Renal Replacement Therapy (RRT). Focuses on improving the management of co-morbid diseases in late stage CKD patients and improving the preparation of patients who need to start RRT, ensuring each patient receives the most suitable permanent access, while minimizing the use of temporary catheters. Ensures every patient receives treatment modality education and dialysis preparation in order to begin RRT at the facility designated by the Nephrology Practice and the patient. Coordinates late stage CKD education, vascular access management support and treatment option initiatives and other patient and primary care physician (PCP) education and support processes that improve patient outcomes and reduce patient hospitalizations.
DUTIES / ACTIVITIES :
- Responsible for driving the FMS culture through values and customer service standards.
- Accountable for outstanding customer service to all external and internal customers.
- Develops and maintains effective relationships through effective and timely communication.
- Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner.
PRINCIPAL RESPONSIBILITIES AND DUTIES
- Partners with Treatment Options Specialists, the Nephrology Practice and FMCNA Operations team to provide, coordinate and integrate Treatment Options and Kidney Disease Education programs to reduce the incidence of acute ESRD onset and improve management of co-morbid diseases for patients starting RRT. Activities include the following:
- Coordinates with Treatment Options Specialists to ensure every patient and family member (if applicable) receives comprehensive information on specific modality advantages and disadvantages, hemodialysis treatments both at home and in-center, peritoneal dialysis, and kidney transplantation as well as education on hemodialysis access types with focus on the health and safety benefits of AV-Fistula or AV-Graft compared to central venous catheters.
- Identifies and addresses patient financial and insurance resources and concerns as needed.
- Coordinates the Nephrology Practice late stage CKD patient population with regard to CKD education, including modality selection, permanent access placement and maintenance and a stable transition to RRT with an expected patient case load of 400-500 patients.
- Utilizes the Acumen ® software application or other appropriate EHR, to develop and maintain a HIPAA compliant database of information about late stage CKD patients in the program providing reports and analyses, identifying trends, anomalies and areas of concern. Participates in the interpretation of summary clinical data and its use in improving late stage CKD care processes.
- Participates in the complex decision-making of modality selection and the creation and maintenance of a permanent dialysis access for patients starting RRT.
- Assesses patients’ knowledge of late stage CKD and treatments, educating and informing patients to enable them to make informed decisions regarding the steps to manage health issues during the transition to RRT including Cardiovascular disease; diabetes; hypertension; anemia; bone disease; disorders of calcium and phosphorus metabolism; and symptomatic neuropathy.
- Participates with Treatment Options Specialists, Nephrology Practice and FMCNA Operations teams to facilitate community-focused education initiatives for Primary Care Physicians (PCPs) such as the following:
- Deliver educational programs designed to build greater awareness in the local medical community of the importance of timely referral of CKD patients for nephrology care by PCP in order to reduce the incidence of acute ESRD onset without the benefit of such care and to improve management of co-morbid diseases for patients starting RRT.
- Identifying PCPs who consistently provide late referrals and educating these providers as to the appropriate procedures and steps to employ to ensure more timely referrals for nephrology care.
- Facilitates “face-to-face” educational meetings with community PCPs to educate them regarding different stages of kidney disease and the timelines regarding the appropriate care and actions for the particular stage in the disease.
- Participates in the collection and analysis of clinical data that supports a dialysis outcomes tracking mechanism for all ESRD patients through the first 120 days of dialysis such as the FMS Incident UltraScore QSR or comparable data report, which includes an evaluation of the patient’s state of health at the time they start dialysis and at the end of 120 days on dialysis.
- Develops processes to promote communication between the Nephrology Practice and other providers such as vascular and PD surgeons to improve the care of late stage CKD patients and improve the opportunity of patients to start RRT with a permanent access.
- Participates in meetings to review the RCC program within the practice and to review pertinent RCC data. Participate in the annual RCC meeting and other meetings as requested by the CKD administrative team.
- Other duties as assigned.
RN Required. Bachelors’ degree preferred.
Current RN license required to practice professional nursing in applicable states
EXPERIENCE AND REQUIRED SKILLS:
- At least 3 years of previous experience in clinical patient care or case management required.
- A combination of hemodialysis, PD, transplantation, CKD education, case management and nutritional training highly valued.
- Renal transplant, dialysis, or CKD patient care preferred.
- Demonstrated knowledge of renal disease and renal transplant required.
- Excellent written and verbal communication skills – good presentation skills.
- Ability to communicate and maintain effective interpersonal relationships at various levels of the organization.
- Understanding of diabetes and cardiovascular disease process and current case management practices required.
- Good understanding of relationship between the dialysis providers and the physician practice.
- Ability to determine when coordination may be performed by telephone or written instruction and when approval by a higher level of authority such as a physician or other health care provider is required.
- Ability to travel with a valid driver’s license.
- Preferred experience in teaching/education and counseling in complex multi-site organization.
- Must be highly self-motivated, dependable and organized with basic computer skills.
Fresenius Medical Care - 9 months ago
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Fresenius Medical Care North America (FMCNA) operates a network of more than 1,800 dialysis clinics located throughout the US. One of the...