• Coordinate with Operations Manager, Clinical Services Manager, Nurse Practitioners, Social Worker, and Case Managers to review patient cases and identify clinical judgement escalations • Support Patients with potentially declining condition to educate on treatment options, ensure patients care aligned with their wishes, and navigate to appropriate resources • Assist patients with identifying their goals, values, preferences, and develop care plan that aligns with patient wishes • Work with patients to develop and/or update advance care plans • Facilitate patient/family communication • Serve as a role model and coach to help peers facilitate ACP and EOL conversations • Provide comfort case management guidance to IKC RNs for patients where palliative care is not available or when patient is not ready to stop dialysis but would like to pursue comfort care • Coordinate care between patients care team (Neph, PCP, dialysis clinic, supportive care resources, etc.) • Develop relationships with supportive care providers • Quickly build empathetic relationships with patients and families • Coordinate care for patients’ care including care transitions, management of complex/at risk patients, managing ongoing needs and establishing a treatment plan in partnership with the care team • Coordinate for streamlined/effective transition of care when needed (discharge planning/ care planning