Registered Nurse Care Navigator Bilingual English/Spanish at Duo Health

San Juan, , Puerto Rico -

Full Time

Start Date

Immediate

Expiry Date

22 Sep, 26

Salary

0.0

Posted On

24 Jun, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Nursing Assessment, Care Coordination, Patient Advocacy, Chronic Kidney Disease Management, Patient Education, Medication Reconciliation, Case Management, Bilingual Communication, Population Health, Interdisciplinary Collaboration, Electronic Health Records, Culturally Appropriate Care

Industry

Medical Practices

Description

Company Mission Duo Health is a new type of medical group designed around the needs of patients living with chronic kidney disease. Our proprietary Health Mobilization™ platform partners multidisciplinary care teams with community nephrologists and activates the clinicians, facilities, and community organizations needed to care for the whole patient. 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 RN (Registered Nurse) Care Navigator serves as a key member of the interdisciplinary care team, supporting patients with Chronic Kidney Disease (CKD) stages 3b, 4, 5, and End-Stage Renal Disease (ESRD). The RN Care Navigator works closely with patients, caregivers, nephrology providers, and community resources to coordinate care, improve health outcomes, reduce barriers to treatment, and enhance the patient experience. This role combines clinical expertise with care coordination and patient advocacy. The RN Care Navigator engages patients through in-home visits, telephonic outreach, telehealth appointments, and collaboration with healthcare providers to ensure patients receive timely, comprehensive, and culturally appropriate care. Location This role provides in-home care throughout the San Juan metropolitan area. Travel to patient homes and community location is required. Work Hours Monday- Friday, 8:00 a.m. – 5:00 p.m. with occasional flexibility to meet patient care needs. Duties and Responsibilities * Manage and support an assigned panel of CF+KD and ESRD patients as part of an interdisciplinary care team. * Conduct comprehensive nursing assessments and identify clinical, social, behavioral, and environmental barriers to care. * Develop, implement, and monitor individualized care plans in collaboration with providers, social workers, patients, and caregivers. * Educate patients and caregivers regarding kidney disease, treatment options, medications, lifestyle modifications, and self-management strategies. * Monitor patient progress and identify changes in condition that require intervention or escalation to a provider. * Coordinate care across healthcare settings, including hospitals, dialysis centers, primary care offices, specialty practices, skilled nursing facilities, home health agencies, and community organizations. * Facilitate transitions of care following emergency department visits, hospitalizations, and discharges. * Support medication reconciliation and patient understanding of prescribed treatment plans. * Assist patients in navigating healthcare services, insurance benefits, transportation resources, and community support programs. * Participate in interdisciplinary team huddles, case reviews, and care planning meetings. * Maintain timely, accurate, and complete documentation within the electronic health record. * Support quality improvement initiatives and population health programs designed to improve patient outcomes and reduce avoidable utilization. * Build trusting relationships with patients and caregivers while promoting patient engagement and self-advocacy. * Maintain confidentiality and comply with all applicable HIPAA, company, and regulatory requirements. * Perform other duties as required may be assigned by direct supervisor. Requirements * Current, unrestricted Registered Nurse (RN) license in Puerto Rico. * Bachelor of Science in Nursing (BSN) preferred. * Bilingual in English and Spanish, with strong verbal and written communication skills. * Minimum of 3 years of clinical nursing experience required. * Care management, case management, population health, chronic disease management, home health, dialysis, nephrology, or value-based care experience preferred. * Experience working with medically complex and underserved patient populations preferred. * Knowledge of community resources and social determinants of health. * Strong organizational, problem-solving, and relationship-building skills. * Ability to work independently while collaborating effectively within an interdisciplinary team. * Must meet Duo Health credentialing requirements, including successful completion of a background check. * Reliable transportation, valid driver's license, and ability to travel to patient homes throughout assigned territory. * Comfortable interacting with patients both in-person and virtually. Competitive Benefits Package * Paid vacation and sick leave in accordance with Puerto Rico law and company policy * Puerto Rico Christmas Bonus (Bono de Navidad) in accordance with applicable law * Paid maternity, paternity, and parental leave in accordance with Puerto Rico law and company policy * Mileage reimbursement for approved business travel * Professional licensure reimbursement * Continuing education and professional development opportunities A Mission-Driven Workplace Join a patient-centered team committed to improving health outcomes and advancing health equity through innovative, relationship-based care, within a positive, collaborative culture that values our people. We offer competitive benefits and actively invest in employee growth, development, and overall well-being.

Responsibilities

The RN Care Navigator manages a panel of patients with chronic kidney disease by conducting assessments and developing individualized care plans. They coordinate care across various healthcare settings and provide essential education to patients and caregivers to improve health outcomes.