Nurse Care Manager

Your Role

As a Nurse Care Manager supporting the Evergreen Aligned (EGA) team with Evergreen Nephrology, you are responsible for supporting care delivery within the EGA model by partnering with Advanced Practice Providers (APPs) to ensure effective execution of individualized care plans for patients with chronic kidney disease, hypertension, diabetes, and congestive heart failure.

This role focuses on enhancing clinical outcomes, patient engagement, and care coordination through education, remote monitoring, medication management, and longitudinal patient support in a virtual care environment.

Role Responsibilities

Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:

• Visit Preparation & Coordination
  • Conducts pre-visit planning by reviewing patient records, identifying care gaps, and ensuring necessary clinical information, laboratory results, and assessments are available for scheduled visits.
• Care Plan Execution & Clinical Support
  • Reinforces APP-directed care plans through post-visit follow-up and ensures patient understanding and adherence.
  • Monitors completion of key care elements including labs, medications, and referrals.
• Chronic Kidney Disease Management & Education
  • Provides stage-based CKD education, reinforcing guideline-directed therapies, and key lifestyle strategies.
  • Supports early patient understanding of disease progression and renal replacement options.
• Hypertension Management & Education
  • Educates accurate home BP monitoring and trends data to identify uncontrolled hypertension or hypotension.
  • Reinforces protocol-driven treatment adjustments and lifestyle interventions.
• Diabetes Management & Education
  • Reviews SMBG/CGM data to identify glycemic trends and support timely escalation of care.
  • Educates on hypo-/hyperglycemia management and reinforces medication adherence and A1c monitoring.
• Congestive Heart Failure Management & Education
  • Monitors weight, blood pressure, symptoms, and other clinical indicators to identify early signs of heart failure exacerbation.
  • Reinforce guideline-directed medical therapy, sodium and fluid management, medication adherence, and self-management strategies while facilitating timely escalation of care to prevent avoidable hospitalizations.
• Medication Management
  • Performs medication reconciliation and identifies adherence barriers, side effects, and safety concerns.
  • Educates patients and coordinates with APPs and pharmacy on refills and therapy optimization.
• Quality Measures and Care Gap Closures
  • Supports achievement of HEDIS, Medicare Stars, and other value-based care quality measures by partnering with APPs, providers, and quality teams to proactively identify, address, and close care gaps through patient outreach, education, and follow-up.
• Remote Patient Monitoring (RPM)
  • Conducts proactive outreach for abnormal or missing data and supports device (DM, HTN, CHF) onboarding and troubleshooting.
  • Drives patient engagement and improves data completeness for clinical decision-making.
• Patient Engagement & Relationship Building
  • Serves as a consistent, trusted point of contact, building rapport through empathetic and culturally competent communication.
  • Addresses concerns and reinforces trust in the care model and longitudinal care.
• Self-Management Education
  • Delivers simplified, low health literacy education using teach-back methods to confirm understanding.
  • Provides clear, actionable guidance to support self-management and adherence.
• Cross-Functional Program Collaboration
  • Partners closely with Program Managers, Care Coordinators, Clinical Educators, Pharmacists, Quality, and other interdisciplinary team members to support patient care objectives and program outcomes.
• Community Provider Collaboration
  • Partners with community nephrologists and primary care providers to ensure coordinated care delivery, address care gaps, support transitions of care, and improve clinical outcomes for patients with chronic conditions.
• Other duties consistent with this role, as assigned.

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license
• 2+ years of clinical experience in chronic disease management (CKD, diabetes, or hypertension)
• Strong patient education and communication skills
• Experience with electronic health records (EHR)
• Clinical judgment and data interpretation
• Patient-centered communication and motivational interviewing
• Collaboration in multidisciplinary teams
• Ability to manage multiple patients in a fast-paced virtual environment
• Strong organizational and follow-through skills
• 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

Preferred Qualifications

• Experience in virtual care, care management, or remote patient monitoring
• Familiarity with value-based care models and quality metrics
• Bilingual (Spanish/English) (as applicable to patient population)