CKD Advanced Practice Provider, Community Based Cincinnati

Job Summary: This community-based role focuses onidentifying, staging, and longitudinally managing members with chronic kidney disease (CKD) acrossAbsoluteCare'sattributed population. The CKD CBP partners with in-home extenders (paramedics, RNs, LPNs) who perform initial assessments and specimen collection, then conducts facilitated telehealth and face-to-face visits to diagnose CKD, optimize guideline-directed medical therapy (SGLT2 inhibitors, RAAS inhibitors), coordinate nephrology referrals, and prepare members for renal replacement therapy when indicated. Working in partnership with the member's primary care provider, interdisciplinary care team, and virtual nephrology consultants, the CKD CBP ensures smooth transitions of care post-hospitalization, closes medication and diagnostic gaps, and supports members in slowing disease progression through whole-person, value-based care. DutiesandResponsibilities: Enrollment& Longitudinal CKD Management Perform enrollment and longitudinal visits (telehealth and face-to-face) with members suspected or confirmedCKD. Conduct clinical assessments, diagnose and stage CKD per KDIGO guidelines (eGFR + albuminuria), and enroll members in theappropriate CKDcare pathway. Initiate andoptimizeguideline-directed medical therapy — SGLT2 inhibitors, RAAS inhibitors, nonsteroidal MRAs — in conjunction with the member's PCP or independently if no PCP isestablished. Ensure renal-adjusted medication dosing;identifyanddiscontinuenephrotoxic agents. Refer to nephrology or other specialists in coordination with the member's primary care team. Provide CKD stage-appropriate education: dietary modifications, exercise, disease progression, and self-management. HospitalDischarge & Transitions of Care Providecommunity-basedmedicalandcare-coordinationservicesforrecentlydischarged members. Partner with the transitional care manager and PCP to execute the discharge plan, perform medication reconciliation, andidentifybarriers to safe transition. Deliver member and family education; gather critical information from the home environment and communicate findings to the care team. AdvancedCKDand Goals of Care Initiate "Strong Start" pathway activities for members with eGFR Initiate palliative care and goals-of-care discussions at any CKD stage, with particular attentiontodeclining dialysis or with limited life expectancy. Care Model & Collaboration Partner with in-home extenders (paramedics, RNs, LPNs, CMAs) forinitialhome visits, vitals, labs, and facilitated video visit handoff. Coordinate with Rubicon virtual nephrology for stage 3 members and in-person nephrologists for stage 4/5. Collaborate with Community Health Workers (CHWs) and Community Transitional Care Managers (CTCMs)to address SDOH barriers, support engagement, and close care gaps. Communicate with external PCPs and specialists to align care plans for members receiving primary care outsideAbsoluteCare. Participate in CKD population health rounds and morninghuddles,review dashboards, pathway enrollment, and medication gap reports. Documentation& Value-Based Care Document using the DSP framework (specific diagnosis with stage/type/complications, clinical status, active plan) to supportaccuraterisk adjustment and HCC capture. Ensure annual recapture of CKD-related and complex medical HCCs withappropriate specificity. Order and track lab monitoring by CKD stage per KDIGO cadence; review and act on all results, including urgent notification for emergent findings (e.g., hyperkalemia) and escalation to nephrology as indicated. Qualifications 2+ years of clinical experience as a Nurse Practitioner or Physician Associate. Multi-setting background (hospital, urgent care, home-based, or community-based) preferred. Active, unrestricted state NP or PA license and DEA registration; board certification (AANP, ANCC, or NCCPA)required. Willingness to learn and apply KDIGO Clinical Practice Guidelines for CKD evaluation and management (nephrology or dialysis experience is beneficial but notrequired— we will train). Familiarity with care transitions, readmission reduction strategies, and chronic disease management for high-risk, medically complex populations with multiple comorbidities. Experience with or willingness to learn telehealth-based care delivery — approximately 50% of this role is conducted via video visits. Familiarity with value-based care models, risk adjustment, and clinical documentation standards (HCC capture, MEAT/DSP criteria) preferred. Behavioral health and substance use disorder experience helpful. Comfort working independently in community settings with remote clinical support; able to manage varying home environments and mobile clinical equipment. Knowledge of local population, geography, community resources, and social determinants of health. Proficiencywith electronic medical records and telehealth platforms. Valid driver's license and reliable transportationrequired; mileage reimbursement provided. Workingconditions: This roleis primarilycommunity-based, with approximately 50% of time spent traveling to member homes and 50% conducting telehealth visits.Some work at the employee’s localAbsoluteCarecenter may be required depending on business needs.The provider will work in varying home environments, including homes of members experiencing housing instability, and must be comfortable adapting to uncontrolled settings. There is potential exposure to blood, bodily fluids, and infectious materials;appropriate PPE(gloves, masks)isrequiredand provided. Use of personalvehicleisrequiredfor daily community travel; mileage reimbursement is provided.Mobile clinical equipment and electronic devices will be provided for field-based work. Physicalrequirements Transport mobile clinical equipment and supplies(up to 20lbs.) in and out of member homes, including navigating stairs, narrow hallways, and walkways in varying conditions. Drive personalvehiclethroughout the day across the assigned market area; daily travel distances will varybut may include remote areas. Remain stationary for extended periods during telehealth visits and documentation (~50% of the role). Bend, stoop, and kneel as needed to conduct assessments in non-clinical home settings (e.g., bedside, floor-level). Use mobile electronic devices and clinical equipment in the field for extended periods. #J-18808-Ljbffr