Home Health Registered Nurse

About the job Home Health Registered Nurse Overview

Registered Nurses are needed for a dynamic, fast‑paced start‑up with an innovative care management position that is transforming the delivery of kidney care. You will be driving to patients’ homes who suffer from chronic kidney disease while working well with ambiguity, drive time, and telehealth components.

• Perform in‑home care management visits to assess and impact patients’ social and behavioral status.
• Work closely with the Care Team to ensure continual progress on all care management goals.
• Coordinate with dialysis providers to ensure seamless transitions of care.
• Create and administer care plans, rather than rendering direct clinical services.
• Perform medical assessments and deliver individual, family, and group education on living with chronic illness, dialysis, and associated comorbidities.
• Engage family and social support groups in the education and care of patients.
• Assess patients and refer them to behavioral health specialists for diagnosis and treatment.
• Help patients understand and follow medical and lifestyle recommendations.
• Serve as the point of contact for patient questions regarding social and behavioral needs.
• Facilitate proactive care decisions, especially related to transplantation, home modalities, and AV fistula placement.
• Initiate patient relationships through enrollment and onboarding processes.
• Document patient updates and progress in the care management platform.
• Identify, vet, and build relationships with local Community‑Based Organizations.
• Introduce patients to appropriate resources and act as the patient advocate.
• Serve as a subject matter expert on social determinants for other members of the Care Team.
• Help prevent costly and traumatic episodes such as avoidable hospitalizations, readmissions, and unexpected kidney failure.

• Must have 2 years of RN experience in one of the following:
  Dialysis Care, Home Health Care, Hospice, or Case Management (CM).
• 2+ years of experience working in care management and/or with chronic illness in medical settings such as home health, dialysis, or hospice.
• Tele‑health experience: ability to take calls remotely on some nights and weekends.
• Self‑starter with the ability to work independently with minimal supervision.
• Show empathy and quickly build relationships with patients and community‑based organizations.
• Excellent verbal communication skills both in person and on the phone.
• Fully vaccinated.
• Willing to travel to the patient’s home.
• 2+ years of experience with CKD/ESRD patients is preferred.
• Bilingual is highly preferred.

• Salary of $80,000.
• Flexible paid leave (PTO), sick days, and vacation policy.
• Full benefits (Medical, Dental, & Vision).
• 401K plan.
• Laptop & Phone allowance (details will be discussed).
• Internal growth opportunities.

Work Monday – Friday 8:00 am – 5:00 pm and occasionally after 5:00 pm. Two‑hour travel radius. Rare domestic travel may be required to headquarters in Nashville, TN.

• Brief screening call with a talent advisor.
• Phone interview with HR.
• Video Zoom interview with the operations manager and leadership.