Job Summary:
In the End Stage Renal Disease (ESRD)program, RN Case Managers provide comprehensive, community-based care coordination for high-need, high-risk individuals, with a focus on those with chronic conditions requiring dialysis. Leveraging clinical expertise, especially in nephrology and renal care, the RN Case Manager ensures person-centered, interdisciplinary support to help members navigate the healthcare system and improve health outcomes.

Working primarily in person and also remote, the RN Case Manager engages dialysis patients with complex medical and psychosocial needs—that include high hospital utilization, transition of care, medication reconciliation, and education on multiple co-morbidities with higher emphasis on dialysis. This position plays a vital role in bridging gaps across acute care, dialysis treatment, social services, and long-term support systems.

Essential Duties and Responsibilities:

• Coordinate care and provide clinical oversight for members receiving dialysis, ensuring smooth transitions between treatment centers, primary care, specialists, and hospital systems.
• Use nursing judgment to assess, plan, implement, and evaluate patient-centered care plans, integrating dialysis-specific needs.
• Educate members on managing ESRD, dialysis adherence, nutrition, medication compliance, vascular access care, and early signs of complications.
• Collaborate closely with nephrologists, nurse practitioners, dialysis centers, and interdisciplinary teams to support optimal renal care.
• Conduct comprehensive assessments, incorporating SMART goals and motivational interviewing techniques.
• Provide in-person visits at dialysis centers to support member engagement and reduce barriers to care.
• Advocate on behalf of members to ensure timely access to renal treatment, specialty services, durable medical equipment (DME), medications, transportation, and other resources.
• Document all care coordination encounters and follow-up actions in the electronic health record (EHR).
• Track and manage hospitalizations, discharges, missed appointments, and urgent care visits, especially related to dialysis complications.
• Enroll members in the ESRD program and maintain compliance with all regulatory and programmatic guidelines.
• Provide culturally competent, trauma-informed care in alignment with ESRD goals and population health strategies.

Minimum Requirements:

Education:

• Current, unrestricted Registered Nurse (RN) license in the state of practice California.
• Associate Degree in Nursing (ADN) required; BSN preferred.

Experience:

• Minimum 2 years of recent experience as an RN in dialysis or nephrology care (required).
• At least 1 year of experience in care coordination, case management, or community health preferred.
• Experience working with complex populations including individuals with behavioral health needs.

Other Requirements:

• Valid driver’s license and reliable transportation.
• Proof of current auto liability insurance per state requirements.
• Proficiency in electronic documentation systems and Microsoft Office applications.

Preferred Skills and Competencies:

• Strong knowledge of ESRD, CKD, dialysis modalities, and vascular access care.
• Skilled in interdisciplinary collaboration and care team leadership.
• Excellent verbal and written communication and clinical documentation skills.
• Demonstrated ability to engage resistant or vulnerable populations.
• Ability to work independently while managing a dynamic caseload.
• Bilingual in English/Spanish.

Work Environment & Physical Demands:

• Frequent community-based travel to dialysis clinics.
• Hybrid schedule may include office and remote work, as applicable.
• Must be able to lift up to 25 lbs occasionally and remain on feet for extended periods during visits.