• Support some of our most complex patients, assisting them in navigating a challenging healthcare system. • Identify the medical, social, emotional, and financial needs of your patients with CKD/ESKD and implement appropriate interventions. • Work autonomously and in collaboration with all members of the healthcare team to coordinate and facilitate quality, consistent, cost-effective care. • 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. • Identify and address social determinants of health including medical, emotional, education, community, and financial concerns. • Assess patients and work to identify unreported medical conditions or changes that may lead to adverse outcomes.