RN Case Manager- Orlando, FL- Hybrid Remote CKD

📋 Description

• • Own the full continuum of care for 60–80 CKD and ESKD patients across the greater Orlando region, acting as the single point of accountability who ensures nothing falls through the cracks. You will review charts, labs, imaging, and dialysis run sheets to surface silent clinical changes, then translate that data into actionable care plans that physicians, dialysis teams, social workers, and community agencies can execute together.
• • Build rapid, trust-based relationships with patients and their families—often in their first week of dialysis or immediately after a hospital discharge—so they see you as their advocate, not another appointment. You will meet them where they are, literally: 60 % of your time is telehealth from your home office, 40 % is windshield time to dialysis units, nephrology practices, skilled-nursing facilities, and occasionally patient homes when safety permits.
• • Triage and prioritize daily: one morning you may stabilize a hyperkalemic patient via phone coaching, the next afternoon you may negotiate a same-day nephrology slot for a transplant evaluation, and by evening you may be arranging transportation vouchers so a patient can pick up newly prescribed binders. Your caseload is dynamic; your clinical judgment keeps it from becoming chaotic.
• • Drive measurable outcomes—fewer avoidable hospitalizations, shorter length of stay, improved Kt/V, higher transplant referral rates—by embedding evidence-based protocols into every interaction. You will document in Epic-based care-management modules, run gap reports, and present trend data to physicians during monthly “huddles,” turning analytics into frontline action.
• • Master the social determinants that derail kidney care: housing insecurity, medication affordability, food deserts, undocumented status, depression, and health literacy gaps. You will partner with DaVita social workers, community health workers, and external agencies to secure emergency grants, SNAP enrollment, or interpreter services within 24–48 hours of identification.
• • Orchestrate seamless transitions of care—hospital to dialysis, dialysis to transplant listing, or home modality training—by creating 7-, 30-, and 90-day roadmaps that include medication reconciliation, follow-up scheduling, and patient education checkpoints. You will own the discharge summary review and ensure every provider along the chain has the same playbook.
• • Educate patients on disease progression, dialysis access care, transplant candidacy, and advance-care planning using teach-back methods and culturally tailored materials. Your goal is autonomy: patients who can articulate their options and make informed decisions even when you are not on the line.
• • Collaborate in a true interdisciplinary village: weekly case conferences with nephrologists, dietitians, vascular access coordinators, and pharmacy specialists; monthly quality-improvement sprints; quarterly strategic summits with DaVita IKC leadership. Your voice shapes policy as much as it shapes individual care plans.
• • Leverage technology to scale empathy: remote patient-monitoring dashboards, secure texting platforms, and AI-driven risk scores alert you to the patient whose missed three treatments or whose phosphorus jumped 2 mg/dL. You will intervene before the crisis, not after.
• • Maintain compliance with CMS, ESRD Networks, and DaVita’s own rigorous quality standards. You will audit your documentation for HEDIS, STAR, and QIP measures, ensuring every click supports both patient care and value-based contracts.
• • Grow continuously through DaVita’s StarLearning portal—CEU-eligible modules on motivational interviewing, transplant navigation, and health-equity frameworks—and optional tuition reimbursement for MSN, CCM, or nephrology certification. Your development plan is co-authored with your manager and updated quarterly.
• • Champion DaVita’s “community first, company second” ethos by participating in local kidney walks, NKF advocacy days, and teammate resource groups. You will help build a culture where every patient—and every teammate—feels they belong.