Nurse Care Manager

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 Nurse Care Manager with Evergreen Nephrology, you are responsible for managing an assigned patient panel and addressing each patient’s specialized needs based on their individual conditions, healthcare needs, goals, and wishes. You will collaborate with a team of physicians, Advanced Practice Providers (APPs), and Interdisciplinary Team (IDT) members. Nurse Care Managers at Evergreen often focus on patients targeted for specific programs such as Chronic Complex Care Management, Compassionate Care Management, Post Acute Care, Transitions of Care, and CKD Management.

While our Nurse Care Manager positions are fully remote, this specific position will support patients in the Central and Eastern Time Zone and must be able to work 8:30a - 5p ET or CT.

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 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 through comprehensive evaluations.
• 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 degree in nursing
• Current RN License is required, Compact License preferred
• Care management experience required
• Certified Case Manager preferred
• 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