Manager

• Support complex CKD/ESKD patients and assist them in navigating a challenging healthcare system
• Conduct medical record review and consultation to identify medical, social, emotional, and financial needs
• Implement appropriate interventions and establish treatment plans in partnership with the care team
• Work autonomously and collaboratively with healthcare team members to coordinate and facilitate quality, consistent, cost-effective care
• Coordinate care transitions, manage complex/at-risk patients, and manage ongoing needs
• Identify and address social determinants of health including medical, emotional, education, community, and financial concerns
• Assess patients to identify unreported medical conditions or changes that may lead to adverse outcomes
• Provide telehealth care from home and travel within the Winchester region for in-person visits to dialysis clinics and nephrology practices
• Monday–Friday schedule; no nights, holidays, weekends or on-call

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