- Manage the overall care management of patient panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations.
- Establish trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
- Perform assessments and identify the needs of panel patients and caregivers based on values, care goals, and individual preferences, translating these into patient-centric actionable care plans.
- Coordinate the interdisciplinary approach to achieving continuity of care and reducing fragmentation, focusing on kidney disease progression management and utilization management.
- Monitor and evaluate the effectiveness of care management plans regularly, modifying interventions as necessary.
- Collaborate with physician partners, community providers, APPs, and other clinical disciplines to create, implement, and manage integrated care plans.
- Facilitate patient and caregiver education on treatment options and empower patients to make informed decisions about their care.
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