Care Coordinator

Summary

Join Evergreen Nephrology as a dedicated Care Coordinator, supporting patients with kidney disease and contributing to a value-based, person-centered care model. This remote position, ideally based in San Diego, CA, involves coordinating care, addressing social determinants of health, and navigating resources for patients. You will collaborate with an interdisciplinary team, leveraging technology to enhance patient outcomes. Responsibilities include patient engagement, care plan development, resource navigation, and advocacy. The role requires healthcare coordination experience, strong communication skills, and proficiency with technology. Evergreen offers a competitive compensation package, including benefits and professional development opportunities.

Requirements

• 3 years of experience in health care coordination, community health work, or similar healthcare related field
• Experience with team-based approach to care
• Excellent working knowledge of community resources
• Exceptional ability to prioritize and task-switch to meet needs of patients and overall care team
• Self-directed and motivated to resolve issues professionally and creatively
• Strong communication and teaching skills
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Ability to work effectively in a primarily remote environment: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wired to the house internet (Cable, Fiber, or DSL) and hardwired to the internet device is recommended
• Team Members must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Responsibilities

• Perform telephonic outreach to enroll and engage patients identified for your clinical program and establish connection as primary point of contact for enrolled patients in the program
• Develop and implement care plans addressing the unique needs of patients, ensuring collaborative and cohesive support across and throughout the patient’s healthcare journey
• Facilitate seamless transitions of care through collaborative pathways across care settings and dialysis centers to ensure strong social support and comprehensive care plans
• Update established patient care plans, as appropriate, to drive enhanced care delivery
• Conduct thorough patient assessments to identify social, economic, and environmental factors impacting members' health, with the goal of recommending gap closures to improve quality and health outcomes for inclusion in the comprehensive care plan
• Connect members to appropriate resources such as housing assistance, transportation, food security, and community support programs
• Guide members in understanding and utilizing health and social services, both within Evergreen Nephrology and with other providers and community-based organizations, to improve access to care and enhance their overall well-being
• Advocate for members by identifying barriers to care, ensuring they receive appropriate support and interventions, and working to address inequities in health access
• Maintain open lines of communication with patients and their families, caregivers, and healthcare teams to ensure coordinated care and support patients through any issues that may arise during the care process
• Ensure accurate and timely documentation of member interactions, assessments, and care plans in accordance with organizational policies and regulatory requirements
• Identify and alleviate stressors and other barriers to quality care through providing educational resources and solutions to patients and their families with the aim of empowering patients to navigate their conditions with comprehensive support
• Other duties as assigned, including cross coverage between markets, when needed

Preferred Qualifications

• You reviewed the Who You Are section of this job posting and immediately felt the need to read That makes you a match for our innovative culture
• You accept that things change quickly in a start-up environment and are willing to pivot rapidly on priorities

Benefits

• Competitive base pay with bonuses
• Paid time off starting at four weeks for full-time employees
• 12 paid holidays per year
• Reimbursement for continuing medical education
• 401k with match
• Health, dental, and vision
• Paid parental
• Robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology