Who We Are
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.
We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.
Who You Are
You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.
Your Role
As a Transitions of Care Nurse Care Manager, you are responsible for collaborating with a team of physicians, Advanced Practice Providers (APPs), and Interdisciplinary Team (IDT) members to manage an assigned patient panel and address each patient’s specialized needs based on their recent hospitalization. Your job duties will include taking full ownership of patient care management within your panel, with an additional focus on helping patients with kidney disease navigate the kidney care continuum and manage their chronic conditions post hospitalization. You will perform assessments to identify needs based on individual values, goals, and preferences, which informs your development of comprehensive care plans for each member. These care plans will be used to coordinate patient care delivery with Evergreen and our JV partner clinicians, network providers, contracted vendors, and community-based services.
While this position is fully remote, you must be able to work 8:30am – 5pm in the Central time zone.
Role Responsibilities
Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:
- Managing the overall care management of patient panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations.
- Establishing trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
- Serving as an advocate and community liaison for patients to ensure proper and timely resources and support while navigating the health care system after hospitalization and maintaining compliance with the primary care team’s/nephrologist’s treatment plan.
- Performing assessments and identifying the needs, including social determinants of health, of panel patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans.
- Ensure timely follow-up appointments, medication reconciliation, and referrals to necessary services.
- Coordinating the interdisciplinary approach to achieving continuity of care and reducing fragmentation, focusing on kidney disease progression management, utilization management, and provider coordination through active care plan management.
- Monitoring and evaluating the effectiveness of care management plans regularly, modifying interventions as necessary.
- Following evidence-based care management guidelines and established workflow protocols to deliver high quality, efficient, patient-centered care that aligns with Evergreen’s goals, quality metrics, and regulatory and payer requirements.
- Collaborating with physician partners, community providers, APPs, and other clinical disciplines to create, implement, and manage integrated care plans.
- Identifying cost-effective measures for patients that support value-based care goals of improving patient outcomes and quality while effectively managing resource utilization.
- Facilitating patient and caregiver education on treatment options and empowering patients to make informed decisions about their care.
- Supporting seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with IDTs.
- Actively participating in clinical huddles and patient care conferences for patients under your care management as needed.
- Engaging in continuous, organizational process improvement to identify opportunities for improvement and execute action plans to optimize care management workflows, patient engagement processes, customer/patient care efforts, and other protocols.
- Preparing reports and other deliverables to communicate program changes or developments to appropriate stakeholders.
- Collecting 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.
Required Qualifications
- Associate Nursing degree with an active RN license (compact license preferred)
- 3+ years of care management experience
- 2+ years of Transitions of Care experience
- Chronic and complex care management experience
- Utilization management experience
- Intermediate skills with MS Office Suite of products including Outlook and Teams
- Able to work effectively in a primarily remote environment:
- Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
- Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
- Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Compensation
The pay range for this role is $90,000 to $103,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.
This role is also eligible for a quarterly bonus.
Benefits
Evergreen Nephrology’s total rewards program is designed to support you in and outside of work. You can expect:
- Paid time off starting at 4 weeks for full-time employees
- 12 paid holidays per year
- Medical, dental, vision and life insurance, including an HSA with employer match
- Reimbursement for continuing medical education for eligible roles
- A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure
- Paid parental leave
- A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology
Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.
If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at [email protected].