AI-ML Engineer

• Home Visits (within 1 hr driving radius) and Telehealth
  
• Opportunity to work in a dynamic, fast paced and innovative care management company that is transforming the delivery of kidney care.
  
• This position will work with underserved populations.
  
• Competitive salary and bonus.
  
• Flexible paid leave and vacation policy.
  
• Laptop, mileage reimbursement, phone allowance, and extra perks available!
  

• Develop and continually adapt an individualized care plan in conjunction with physicians
  
• Perform frequent daily in-home care management visits to execute care management plans
  
• Serve as the primary point of contact and be the first call when members have questions about their health
  
• Prepare care recommendations and escalations for plan members, write reports regarding the same and communicate the same in weekly internal case rounds
  
• Understand the needs of the health plan managed care clients and prioritize plan member visits, recommendations and focus accordingly
  
• Use personal communication skills, patience and diligence to engage plan members and their caregivers
  
• Perform post-op and hospital discharge visits to help plan members through vulnerable transitions
  
• Review and document plan member updates and progress in care management platform
  
• Monitor biometric data and follow approved protocols for any necessary interventions
  
• Inventory and reconcile medications and coordinate with pharmacists and prescribers
  
• Perform plan member health assessments and surveys as required
  
• Deliver individual and group education on CKD, ESRD, dialysis and associated co-morbidities
  
• Encourage medication and treatment adherence through frequent contact with members
  
• Engage positively with social workers to facilitate social and behavioral needs to of plan members
  
• Educate members and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placement
  
• Coordinate with dialysis providers to ensure transitions of care are seamless
  

Requirements

• NJ State RN license or Compact License
  
• Graduate of an accredited school of nursing
  
• 2+ years previous experience working in care management and/or with Chronic Kidney Disease (CKD)/End Stage Renal Disease (ESRD) patients preferred.
  
• Must have Home Health and/or Hospice experience.
  
• Ability to take call remotely on some nights and weekends
  
• Ability to drive to patients homes