*Determine that cases are assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial)*Validate that cases/requests for services require additional research*Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources)*Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)*Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)*Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)*Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)*Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs)*Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)*Apply understanding of medical terminology and disease processes to interpret medical/clinical records*Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)*Review care coordinator assessments and clinical notes, as appropriate*Identify relevant information needed to make medical or clinical determinations*Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical)

*assess members' current health status*identify gaps in barriers in treatment plans*provide patient education to assist with self-management*interact with Medical Directors on challenging cases*coordinating care for members and services as needed*educating members on disease processes*encouraging members to make healthy lifestyle changes*ensure that members discharged from the hospital receive the necessary services and resources*documenting and tracking findings

*Performs ongoing, systematic collection and analysis of patient data pre – during – post hemodialysis treatment for assigned patients and documents in the patient medical record, adjusts or modifies the treatment plan as indicated*Recognizes aspects and implications of patient status that vary from normal and reports to or collaborates with appropriate health team members for input.*Assesses daily assigned patient care needs and collaborates with direct and ancillary patient care staff as needed.*Directs and provides, in collaboration with direct and ancillary patient care staff, all aspects of the daily provision of safe and effective delivery of chronic hemodialysis therapy to assigned patients.*Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification and effectiveness.*Ensures correct laboratory collection, processing and shipping procedures are performed and reschedules missed or insufficient laboratory collections.*Initiates or assists with emergency response measures.*Promotes infection control, equipment and environmental safety.*Assesses, collaborates and documents patient/family’s basic learning needs to provide initial and ongoing education to patients and family*Identifies expected outcomes, documents and updates the nursing assessment and plan of care for assigned patients through collaboration with the Interdisciplinary Team.*Ensures patient awareness related to transplant and treatment modality options.*Makes referrals to Social Worker and Registered Dietitian as appropriate for individual patient education and counseling.*Supports and promotes the FMCNA’s mission, vision, values, and customer service philosophy.