Job description
The DaVita Integrated Kidney Care Supportive Care Case Manager/Palliative Care (RN) serves as a clinical subject matter expert and specialized support layer for patients with advanced Chronic Kidney Disease (CKD) and End Stage Kidney Disease (ESKD) who are experiencing significant health decline and assisting them in navigating a challenging healthcare system.
This role leverages deep expertise in Palliative care to lead complex Goals of Care (GOC) and advance care planning discussions, navigate patients to comfort resources and empower patients to make healthcare decisions aligned with their values.
Responsibilities
- This role functions autonomously to support the primary Integrated Kidney Care team with high-acuity patients, coordinating between the dialysis center, Nephrologist, primary care, and external agencies to facilitate quality, consistent, cost-effective care, ensuring a holistic, compassionate approach to end-of-life planning, symptom management to minimize care fragmentation and prevent unnecessary hospitalizations.
Requirements
- Must have Palliative Care Experience
Full-time Fully Remote position, work from your designated home office
Monday- Friday schedule with the ability to accommodate patient’s availability. We serve patients nationwide
Collaborate with Operations Manager, Clinical Services Manager, Nurse Practitioners, Social Worker, and Case Managers to review patient cases, identify gaps/barriers, and coordinate on advance patient care plan
Lead complex conversations and conduct in-depth, compassionate telephonic discussions to support patients with potentially declining conditions to educate on treatment options, ensure patients care aligned with their wishes, and navigate to appropriate resources
Lead Goals of Care (GOC) discussions with ability to translate patient wishes into actionable care plans; document and update GOC to ensure alignment across the entire healthcare team (Nephrologists, Dialysis Centers, IKC RNs).
Educate patients on Advanced Directives (MOLST/POLST) and encourage completion to prevent unwanted aggressive interventions.
Assess symptom burden (pain, anxiety, dyspnea) and collaborate with providers to implement nursing interventions that improve Quality of Life (QOL).
Strong clinical acumen with the ability to recognize the trajectory of chronic illness, identify critical changes to proactively identify those at risk of rapid decline or readmission and intervene immediately for transition to supportive care.
Expertly assess patient appropriateness and readiness for palliative care or hospice and facilitate seamless transitions to these external services.
Educate pts on curative treatments, palliative support, and hospice care, to help reduce barriers to access.
Exceptional active listening and motivational interviewing skills; ability to discuss sensitive topics (death, dying, prognosis) with empathy and clarity.
Ability to work independently in a remote environment, managing a caseload of high-complexity patients with minimal supervision.
Facilitate patient/family communication and develop and/or update advance care plans.
Provide comfort case management for patients where palliative care is not available or when patients are not ready to stop dialysis but would like to pursue comfort care
Coordinate care for patients’ care including care transitions, management of complex/at risk patients, managing ongoing needs and establishing a treatment plan in partnership with the care team
Requirements: Minimum of 2+ years experience as an RN in Palliative medicine required
Minimum of five (5) years experience as an RN required
2+ years of care plan creation, proactive discharge planning and utilization.
Current RN License is required, BSN preferred.
Current Cardiopulmonary Resuscitation (CPR) or Basic Life Support (BLS) certification.
Proficiency in EMR systems (Cerner), Microsoft Office (Teams, Excel), and virtual communication platforms.
Home office with internet connectivity at a minimum of 1MB upload and 1MB download speed required.
Preferred Qualifications: IKC Experience as a DaVita IKC RN Case Manager
2+ years of Case Management or Chronic Care Management
Minimum of two (2) years experience in renal nursing preferred
Compact License - Highly preferred
About DaVita Kidney Care
DaVita means “to give life,” reflecting our proud history as leaders in dialysis—an essential, life-sustaining treatment for those living with end stage kidney disease (ESKD). Today, our mission is to minimize the devastating impacts of kidney disease across the full spectrum of kidney health care.
At DaVita, we’re a community first and a company second. We care for our teammates with the same intensity with which we care for our patients—and encourage our teammates to bring their hearts to work. That is, we can be the same people inside and outside of work because for us, it’s not work, it’s our passion.
