Job Description

Position Summary: The Home Dialysis Navigator provides direct participant navigation and nonclinical care coordination to support people with kidney failure in southern West Virginia through the process of starting and staying on home dialysis. Under the direction of the Project Manager, the Navigator identifies and helps address nonclinical barriers to home dialysis, coordinates access to education and community resources, assesses caregiver support and backup needs, and facilitates timely follow-up with regional healthcare partners. Each Navigator is assigned to a designated region and works collaboratively with the region's designated partner organizations.

This is a new, full-time grant-funded position. Continuation beyond the grant period depends on available funding.

Duties

• Contact referred patients in person, by phone, and by telehealth; explain the program; and complete enrollment and consent.
• Coordinate home dialysis education with nephrology and dialysis care teams.
• Conduct non-clinical screenings and home visits to identify barriers to home dialysis and develop individualized plans to address them.
• Screen patients for food and nutrition needs and connect them with appropriate resources.
• Connect patients with community resources such as transportation, utility assistance, and caregiver support, and follow up to confirm they received help.
• Assess caregiver support and help patients and families plan for backup care.
• Stay in contact with patients through home dialysis training, initiation, and the first months at home.
• Coordinate with nephrologists, dialysis providers, hospitals, and community partners in the assigned region, including regional partner case managers.
• Refer clinical questions to the patient's care team.
• Maintain accurate, timely records of patient contacts, referrals, and outcomes in the program's case management system.
• Participate in team meetings and program improvement activities.
• Perform other duties as assigned.

Other Requirements:

• Strong communication skills and ability to build trust with patients and families
• Ability to manage a caseload, work independently, and meet deadlines
• Understanding of confidentiality and professional boundaries
• Proficiency in Microsoft Office and electronic records systems
• Valid driver’s license and reliable transportation

Location: Hybrid

Education: Associate or bachelor’s degree in nursing with current West Virginia RN license (BSN preferred), or bachelor’s or master’s degree in social work with current West Virginia social work license. Equivalent relevant education and experience may be considered in accordance with organizational policy.

Experience: Minimum of two (2) years of experience in dialysis or nephrology care. Home dialysis experience preferred. Experience coordinating referrals, documenting participant interactions, and working with community-based organizations preferred. Knowledge of food assistance programs, community resource networks, or kidney disease services is an advantage.

Working Conditions: The position requires frequent travel throughout the assigned region to meet with participants, coordinate with regional partners, and support program activities. The Navigator may conduct outreach by telephone, electronically, and in person, as appropriate to program protocols. A valid driver's license and reliable transportation is required.

Other Duties: This job description describes the principal duties and responsibilities of the position. Additional duties may be assigned as necessary to support program objectives, consistent with the employee's role, organizational policies, and applicable funding requirements.