Registered Nurse (VBC) - US Renal Care- Value Based Care Kidney Link - Remote
(2023-10 - 2025-08)
Registered Nurse acts as a clinical coordinator for chronic kidney disease (CKD) patients, providing in-person and telephonic education to manage health, prevent hospitalizations, and assist with dialysis/transplant transitions. The role focuses on improving patient outcomes and reducing costs through proactive care management.
- Case Management: Engaging with patients, families, and support networks to manage ongoing education, medication, and care plans.
- Proactive Intervention: Identifying and managing high-risk patients to delay disease progression and reduce hospital readmissions.
- Collaborative Care: Working with nephrologists, care teams, and insurance providers to manage care quality and cost-effectiveness.
- Patient Education: Offering education on CKD, treatment options (transplant, home therapy, or in-center dialysis), and behavior modifications.
- Documentation: Utilizing data to track and document patient health metrics and clinical outcomes.
Medical Surgical Staff RN - Raleigh General Hospital - Raleigh, Virginia
(2023-04 - 2023-08)
Travel Assignment providing direct patient care utilizing nursing processes in accordance with applicable scope and standards of practice. Treats medical, surgical, telemetry and oncology patients requiring nursing care, including assessment, problem identification, pre-operative assessment, pre and post operative care. Initiates life saving procedures, providing emergency care for each patient and palliative care to terminal patients.
- Performs assessment skills.
- Plans nursing care.
- Documents to reflect plan of patient care, interventions, change in condition, assessments, etc.
- Intervenes with appropriate action after needs are identified.
- Evaluates the assessment, planning and intervention process.
- Demonstrates professional and personal development.
- Delivers direct patient care appropriate to the age of patient served including adult and geriatric patients.
Outpatient Hemodialysis Charge Nurse - University of Virginia - Zion Crossroads, Virginia
(2022-07 - 2023-02)
Charge nurse responsible for outpatient hemodialysis services focusing on relationship-based care, expert caring, empowered leadership, continuous learning, quality achievement, and innovation.
- Relationship Based Care - Self and Colleagues: reflects the influence of the nurse's relationship with self, colleagues and patient/family on the patient experience.
- Relationship Based Care - Patients and Families: reflects the influence of the nurse's relationship with self, colleagues and patient/family on the patient experience.
- Expert Caring: encompasses clinical assessment, planning, prioritizing, coordinating and implementation of care.
- Empowered Leaders: demonstrate knowledge of and actively participate in shared governance.
- Lifelong Learners: encompasses professional development through formal education, professional certification, internal and external learning opportunities and recognizes the value of external professional organizations. Supports onboarding of new team members and precepts as applicable.
- Quality Achievement: includes adherence to clinical documentation guidelines, comprehension of outcomes data, engagement in performance improvement activities and commitment to standard work.
- Innovation: is demonstrated by application of technologies that support patient care, actively seeking to implement evidence based practice and new knowledge generated by nursing research.
LTSS Field Service Coordinator / Case Manager - Anthem, Inc. (Amerigroup) - Note Anthem Inc is now Elevance Health - Indianapolis, Indiana
(2015-02 - 2021-08)
Field Service Coordinator and Case Manager RN responsible for overall management of member's case within the scope of licensure; provides supervision and direction to non RN clinicians participating in the member's case in accordance with applicable state law and contract; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum.
- Responsible for performing telephonic or face to face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical health, behavioral health, social services and long term services and supports.
- Identifies members for high risk complications and coordinates care in conjunction with the member and the health care team.
- Manages members with chronic illnesses, co morbidities, and or disabilities, to insure cost effective and efficient utilization of health benefits.
- Obtains a thorough and accurate member history to develop an individual care plan.
- Establishes short and long term goals in collaboration with the member, caregivers, family, natural supports, physicians.
- Identifies members that would benefit from an alternative level of care or other waiver programs.
- Overall responsibility to develop the care plan for services for the member and ensures the member's access to those services.
- Assist with the implementation of member care plans by facilitating authorizations referrals for utilization of services, as appropriate, within benefits structure or through extra contractual arrangements, as permissible.
- Interfaces with Medical Directors, Physician Advisors and or Inter Disciplinary Teams on the development of care management treatment plans.
- Problem solving with providers, claims or service issues.
- Collaborates with In House Service Coordination Team to develop, monitor, evaluate and revise the member's care plan to meet the member's needs as often as is needed.
Acute Care Inpatient Services Staff RN - Fresenius Medical Care North America - Lexington, Massachusetts
(2014-03 - 2014-10)
Deliver safe and effective patient care in compliance with established company standards; hospital contracted policies and procedures, inpatient renal services policies and procedures, as well as regulations set forth by the corporation, state, and federal agencies. Responsible for direct patient care of assigned patients in the Inpatient Renal Replacement and Aphaeresis Services setting.
- Responsible for reporting all new or unusual incidents, information, complaints, or problems to the pertinent inpatient program manager and other parties to notify per the Adverse Event Report requirements.
- Collaborates with diverse healthcare team.
- Provides and requests information from other team members as they receive and discharge patients from care according to policy.
- Initiates, documents, and completes ongoing QAI activities including monthly reports as directed by the relevant inpatient program manager.
- Responsible for the compliance, support and delivery of all relevant company and contracted facility policies and procedures.
- Responsible for direct patient care of assigned patients in the Inpatient Renal Replacement and Aphaeresis Services setting and providing the appropriate treatment technique for assigned patients as prescribed in all modality procedures.
Regional Hospital Case Manager - LHC Group - Lafayette, Louisiana
(2012-01 - 2013-11)
Served as a clinical liaison position between health care providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: (1) following the receipt of a valid referral for home health or hospice services, directly communicating with and assessing the patient to improve the patient's transition from the inpatient to the home setting; and (2) developing the referral relationships of the agency within the community, in accordance with agency policies and procedures.
Home Therapies Program Manager - Fresenius Medical Care North America - Dallas, Texas
(2012-06 - 2012-10)
Accountable for FMS Home Therapies Program including assessment of patients' home environment if needed. Accountable for timely completion of patient care plans by organizing meetings of the health care team to discuss patient care plans and resolve patient problems. Maintains and communicates efficient and timely patient schedules to ensure maximization of the facility station efficiency.
