Chronic Kidney Disease Community Based Provider (CKD CBP) Cleveland

Chronic Kidney Disease Community Based Provider (CKD CBP) Cleveland 2.9 2.9 out of 5 stars Cleveland, OH $150,000 - $165,000 a year AbsoluteCare 29 reviews $150,000 - $165,000 a year AbsoluteCare AbsoluteCare is a value-based care organization serving high-risk Medicaid and Medicare populations across Ohio. We go Beyond Medicine to deliver whole-person care through interdisciplinary teams embedded in the communities we serve. The CKD CBP role is central to our mission of slowing disease progression, reducing avoidable hospitalizations, and meeting members where they are — literally. Job Summary This community-based role focuses on identifying, staging, and longitudinally managing members with chronic kidney disease (CKD) across AbsoluteCare's attributed population. The CKD CBP partners with in-home extenders (paramedics, RNs, LPNs) who perform initial assessments and specimen collection, then conducts facilitated telehealth and face-to-face visits to diagnose CKD, optimize guideline-directed medical therapy (SGLT2 inhibitors, RAAS inhibitors), coordinate nephrology referrals, and prepare members for renal replacement therapy when indicated. Working in partnership with the member's primary care provider, interdisciplinary care team, and virtual nephrology consultants, the CKD CBP ensures smooth transitions of care post-hospitalization, closes medication and diagnostic gaps, and supports members in slowing disease progression through whole-person, value-based care. Duties and Responsibilities Enrollment & Longitudinal CKD Management Perform enrollment and longitudinal visits (telehealth and face-to-face) with members suspected or confirmed CKD. Conduct clinical assessments, diagnose and stage CKD per KDIGO guidelines (eGFR + albuminuria), and enroll members in the appropriate CKD care pathway. Initiate and optimize guideline-directed medical therapy — SGLT2 inhibitors, RAAS inhibitors, nonsteroidal MRAs — in conjunction with the member's PCP or independently if no PCP is established. Ensure renal-adjusted medication dosing; identify and discontinue nephrotoxic agents. Refer to nephrology or other specialists in coordination with the member's primary care team.

Provide CKD stage-appropriate education:

dietary modifications, exercise, disease progression, and self-management. Hospital Discharge & Transitions of Care Provide community-based medical and care-coordination services for recently discharged members. Partner with the transitional care manager and PCP to execute the discharge plan, perform medication reconciliation, and identify barriers to safe transition. Deliver member and family education; gather critical information from the home environment and communicate findings to the care team. Advanced CKD and Goals of Care Initiate "Strong Start" pathway activities for members with eGFR