PURPOSE AND SCOPE:|
Supports FMCNA’s mission, vision, core values and customer service philosophy and adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements.
Contributes to the improvement in the quality of life for late stage Chronic Kidney Disease (CKD) and early End Stage Renal Disease (ESRD) patients and the reduction of Medicare Trust Fund expenditure for the care of complications related to the diseases, by focusing on improving the management of co-morbid diseases in CKD patients and improving the preparation of patients who need to start Renal Replacement Therapy (RRT). Ensures each patient receives the most suitable permanent access, while minimizing the use of temporary catheters and that the pertinent patients receive treatment modality education and dialysis preparation to begin RRT at the facility designated by the practice and the patient. Coordinates and/or participates in CKD education, vascular access management support and treatment option initiatives and other patient education and support processes that improve patient outcomes, reduce patient hospitalizations, result in improved patient morbidity and mortality, and lower the use of inpatient and outpatient healthcare resources.
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
Acts as a liaison between FMCNA, Nephrology Practice Physicians and pertinent managers, providing support to initiatives and strategies focusing on improving CKD and ESRD patient outcomes, to reduce the number of late referrals to the nephrology practice, and to reduce the number of patients starting dialysis with a temporary catheter. Collaborates with the pertinent stakeholders to provide the appropriate education regarding modality treatment and options.
Utilizing the Acumen® software application or other appropriate electronic health record (EHR), develops and maintains a HIPPA compliant database of information regarding patients in the programs. Provides reports and analyses, identifying trends, anomalies, and areas of concern.
Partners with Treatment Options Specialists, the Nephrology Practice and FMCNA Operations team to develop programs and tools to provide comprehensive information to allow patients to have a stable and more optimal transition to ESRD services at the facility designated by the nephrology practice and patient resulting in healthier and better prepared patients. Programs and tools incorporate:
Assists with, and contributes to, programs designed to manage co-morbid diseases such as hypertension, protenuria, diabetes and other CKD related complications ensuring the appropriate interaction and communication between PCP, Nephrology team and the patient.
- Consistent Pre-ESRD tracking of all CKD patients using the Acumen or another recognized software application. Obtains and inputs pertinent patient demographic information from practice according to defined procedures ensuring compliance with all pertinent regulatory requirements and restrictions.
- Contributing to and facilitating timely referral initiatives such as when patients should be sent to the Nephrology practice by Primary Care Physicians (PCP) to improve management of co-morbid diseases, reduce progression of CKD, and increase the number of patients surviving late stage CKD or receiving a transplant.
- Identifying PCPs who consistently provide late referrals and assisting with educating these Providers concerning the appropriate procedures and steps to employ to ensure more timely referrals to the Nephrology Practice.
- Facilitates regular “face-to-face” educational meetings with community referring Primary Care Providers to educate Providers regarding the different stages of kidney disease and the timelines regarding the appropriate processes of care and actions for the particular stage in the disease.
Partners with local Treatment Options Specialist to coordinate and integrate Treatment Options programs and Kidney Disease Education plans for stage IV and V patients, facilitating communication between PCP, Nephrology team and the patient. This includes:
- Measures patients’ knowledge regarding CKD and related treatments, educating and informing patients to enable them to make informed decisions regarding the steps to mitigate the progression of their renal disease, and the prevention and management health issues such as cardiovascular disease; diabetes; hypertension; anemia; bone disease; disorders of calcium and phosphorus metabolism; and symptomatic neuropathy.
- Informs patients about potential impairments in functioning and well-being, as a result of non compliance with recommended treatment plans.
- Utilizes clinical judgment, independent analysis and management of data in Acumen or other approved database, critical thinking skills and detailed knowledge of case management programs, medical policies, clinical and compliance guidelines to identify, review, assess, implement and monitor programs for CKD patients according to their identified health care needs.
- Ensures patients receive the appropriate education and information in regard to appropriate treatment options
- Contributes to the development by the PCP and the Nephrologist of joint patient care plans for CKD patients.
- Collaborates with the Nephrologists and PCP, appropriate clinical staff and other members of the healthcare team to develop a care plan for CKD patients followed by the RCC.
Collaborates with the practice to develop 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. Coordinates with local appropriate case managers such as RightStart managers to collect this information:
- Coordinating the tracking with TOPs Specialists to ensure that 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.
- Ensuring provision of education regarding hemodialysis access types focusing on the health and safety benefits of AV-Fistula or AV-Graft compared to central venous catheters.
- Addressing patient financial and insurance resources and psychosocial counseling concerns as needed.
Other duties as assigned.
- Reviews and tracks Incident UltraScore QSR metrics for all physicians or comparable data reporting
- Identifies Physicians with catheter rates above target
- Coordinates with local Case Managers such as RightStart managers and clinical staff to ensure that every patient starts dialysis with appropriate preventative health measures activities and ongoing RCC training.
PHYSICAL DEMANDS AND WORKING CONDITIONS:
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Day to day work includes desk and personal computer work and interaction with patients, patient families, facility staff, physicians and the community at large. The position requires travel between facilities and various locations within the community. Travel to regional, divisional and corporate meetings may be required. The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. Considerable travel required.
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 dialysis nursing experience in patient care or case management 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 renal and diabetes 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 and valid driver’s license.
Preferred experience in teaching/education and counseling in complex multi-site organization.
Must be highly self-motivated, dependable and organized.
Fresenius Medical Care - 11 months ago
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