Care Coordinator

Summary

Join Evergreen Nephrology as a Care Coordinator and make a real difference in the lives of kidney disease patients. You will be a vital part of an interdisciplinary team, providing exceptional patient service and care coordination. Leveraging an integrated technology platform, you will focus on identifying and addressing Social Determinants of Health, assisting patients in navigating the healthcare system, and achieving better health outcomes. This fully remote position requires strong communication, problem-solving, and time management skills. You will work within a specific time zone and must meet minimum internet speed requirements. Evergreen Nephrology offers a competitive compensation package, including benefits such as paid time off, health insurance, and a 401(k) with a match.

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
• 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
• Under the direction of your Nurse Care Manager (NCM), 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 and
• In collaboration with your NCM, 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 and
• 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 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
• 401(k) with match
• Paid parental leave
• A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology