• Manage the overall care management of patient caseload by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations. • Facilitate seamless transitions for nephrology patients from a Skilled Nursing Facility to home or community. • Collaborate with hospital discharge planners, providers and SNF staff to ensure patients’ needs are addressed. • Monitor patient progress in skilled nursing facilities and identify barriers to timely discharge. • Actively participate in clinical huddles, IDT meetings, and patient care conferences for patients under your care management. • Develop and implement strategies to optimize length of stay while maintaining high-quality care. • Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with internal and external care team stakeholders. • Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey. • Perform assessments and identify the needs, including social determinants of health, of caseload patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans. • Identify and develop SNF stakeholders and foster relationships for communication and coordination of care. • Identify areas for improvement in post-acute care processes and share or implement evidence-based solutions. • Engage in continuous, organizational process improvement to identify opportunities and execute action plans to optimize care management workflows, patient engagement processes, customer/patient care efforts, and other protocols. • Prepare reports and other deliverables to communicate program changes or developments to appropriate stakeholders • Collect data to prepare and deliver reports alongside program leaders on program success, patient outcomes, and patient/caregiver satisfaction. • Other duties consistent with this role, as assigned.