RN Navigator - CKD

About the role

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.

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.
• 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 op

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