Family Practice/Primary Care Nurse Practitioner

AbsoluteCare

AbsoluteCare is a value-based care organization serving high-risk Medicaid and Medicare populations across Ohio. We go Beyond Medicine to deliver whole-person care through interdisciplinary teams embedded in the communities we serve. The CKD CBP role is central to our mission of slowing disease progression, reducing avoidable hospitalizations, and meeting members where they are literally.

Job Summary

This community-based role focuses on identifying, staging, and longitudinally managing members with chronic kidney disease (CKD) across AbsoluteCare's attributed 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.

Duties and Responsibilities

Enrollment & Longitudinal CKD Management

• Perform enrollment and longitudinal visits (telehealth and face-to-face) with members suspected or confirmed CKD.

• Conduct clinical assessments, diagnose and stage CKD per KDIGO guidelines (eGFR + albuminuria), and enroll members in the appropriate CKD care pathway.

• Initiate and optimize guideline-directed medical therapy SGLT2 inhibitors, RAAS inhibitors, nonsteroidal MRAs in conjunction with the member's PCP or independently if no PCP is established.

• Ensure renal-adjusted medication dosing; identify and discontinue nephrotoxic 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.

Hospital Discharge & Transitions of Care

• Provide community-based medical and care-coordination services for recently discharged members.

• Partner with the transitional care manager and PCP to execute the discharge plan, perform medication reconciliation, and identify barriers to safe transition.

• Deliver member and family education; gather critical information from the home environment and communicate findings to the care team.

Advanced CKD and 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 attention to declining dialysis or with limited life expectancy.

Care Model & Collaboration

• Partner with in-home extenders (paramedics, RNs, LPNs, CMAs) for initial home 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 outside AbsoluteCare.

• Participate in CKD population health rounds and morning huddles, 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 support accurate risk adjustment and HCC capture.

• Ensure annual recapture of CKD-related and complex medical HCCs with appropriate 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

• Nurse Practitioner or Physician Associate with 2+ years of clinical experience; 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 not required 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.

• Proficiency with electronic medical records and telehealth platforms.

• Valid driver's license and reliable transportation required; mileage reimbursement provided.