Company Mission
Duo Health is a value-based care organization focused on improving outcomes for patients living with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Our proprietary Health Mobilization™ platform connects multidisciplinary care teams with community nephrologists and other healthcare partners to deliver comprehensive, high-touch patient care.
Our interprofessional care teams comprised of Physician Assistants, Nurse Practitioners, social workers, and care navigators deliver high-touch, comprehensive care to a small panel of patients. Collaboration is central to our intensive psychosocial model, which includes assessment, medication management, social support, and behavioral health services. Duo Health is committed to building a workforce that reflects the diversity of the communities we serve, and we strongly encourage applicants whose work demonstrates a dedication to diversity, equity, and inclusion.
Job Description
The Specialized ESRD Advanced Practice Provider (APP) delivers comprehensive care to patients with ESRD and late-stage CKD. This role manages a dedicated panel of approximately 100-125 patients, providing primarily in-home visits and individualized clinical management. The APP collaborates with nephrologists, dialysis centers, and interdisciplinary care teams to improve patient outcomes, reduce avoidable hospitalizations, and coordinate care.
Duties and Responsibilities
- Manage a dedicated panel of 100-125 patients with ESRD and late-stage CKD (stages 4-5), primarily through in-home visits.
- Assess and manage vascular access, anemia, fluid status, hypertension, and other ESRD-related conditions.
- Coordinate with nephrologists and dialysis centers regarding treatment plans, dialysis adequacy, and patient needs.
- Manage complex medication regimens, including renal dose adjustments and avoidance of nephrotoxic medications.
- Identify transplant-eligible patients and initiate referrals as appropriate.
- Complete post-hospitalization follow-ups and coordinate transitions of care.
- Maintain accurate clinical documentation supporting HCC coding, risk adjustment, and quality measures.
- Participate in team huddles, care coordination, clinical training, and continuous improvement initiatives.
- Meet established goals related to quality, utilization, patient engagement, and clinical outcomes.
- Adhere to company policies, HIPAA regulations, and applicable clinical and regulatory requirements.
- Perform other duties as assigned by supervisor.
Required Qualifications
- Active, unrestricted Nurse Practitioner or Physician Assistant license in the state of practice.
- Current national certification through an applicable certifying organization, such as ANCC, AANP, or NCCPA.
- Experience managing complex chronic conditions in primary care, geriatrics, or a related clinical setting.
- Strong clinical assessment, decision-making, and documentation skills.
- Proficiency in electronic health records (EHR).
- Strong communication and collaboration skills.
- Valid driver's license and reliable transportation for in-home patient visits.
- Commitment to patient-centered care and patient confidentiality.
- Preferred Qualifications
- Experience in nephrology, dialysis, CKD, or ESRD management.
- Experience in value-based care or Medicare Advantage.
- Experience with quality improvement, risk adjustment, and utilization management.
- CNN-NP (Certified Nephrology Nurse-Nurse Practitioner) certification or willingness to pursue nephrology-focused training.
Competitive Benefits Package
- Competitive base compensation and performance-based bonus.
- Medical, dental, and vision insurance.
- Flexible Spending Account (FSA) and Health Savings Account (HSA) options.
- Paid maternity, paternity, and parental leave.
- Structured six-week onboarding and specialized ESRD clinical training.
- Paid time off and company holidays.
- 401(k) with company match.
- Malpractice coverage.
- Annual continuing medical education (CME) opportunities.
- Professional development opportunities, including support for nephrology-focused certification, in accordance with company policy.
Work Environment and Physical Requirements
This position primarily involves in-home patient visits throughout the assigned geographic market, with occasional travel for team meetings and training. Reliable transportation and the ability to travel between patient locations are required.