RN Navigator

Summary

Join Evergreen Nephrology as a CKD RN Navigator and provide comprehensive care coordination, education, and support to patients with chronic kidney disease. You will serve as a liaison between patients and the healthcare team, optimizing patient outcomes and ensuring seamless transitions of care. Leveraging an integrated technology platform, you'll collaborate with an interdisciplinary team to develop and implement care plans. Responsibilities include patient engagement, care coordination, disease progression monitoring, addressing social determinants of health, resource navigation, patient advocacy, communication, documentation, and education. This role requires a Registered Nurse license, a BSN (preferred), and 5 years of experience (3 in nephrology, dialysis, transplant coordination, or chronic disease management). Evergreen offers a competitive compensation package, including benefits such as paid time off, 401k matching, health insurance, and paid parental leave.

Requirements

• Registered Nurse (RN) with active state licensure
• 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
• You have the ability to work effectively in a primarily remote environment: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wired to the house internet (Cable, Fiber, or DSL) and hardwired to the internet device is recommended
• Team Members must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Responsibilities

• Provide care coordination, education, and support to patients with chronic kidney disease (CKD) across various stages of the disease
• Serve 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
• 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
• 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
• Via telephone; outreach, enroll and engage patients identified for your clinical program
• Influence and collaborate with Nephrologist team to establish trust and relationships with patients
• Using clinical expertise and critical thinking, assess for care gaps in quality and support 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
• 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
• 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
• 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
• 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
• 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
• Ensure accurate and timely documentation of patient interactions, assessments, and care plans in accordance with organizational policies and regulatory requirements
• 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 as assigned, including cross coverage between markets when needed

Preferred Qualifications

Bachelor of Science in Nursing (BSN)

Benefits

• Competitive base pay with bonuses
• Paid time off starting at four weeks for full-time employees
• 12 paid holidays per year
• Reimbursement for continuing medical education
• 401k with match
• Health, dental, and vision insurance
• Paid parental leave