Specialized ESRD Nurse Practitioner

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.