MDS Nurse Care Manager - Post Acute Care

Summary

Join Evergreen Nephrology as a Post Acute Nurse Care Manager and collaborate with Skilled Nursing Facilities to manage nephrology patients post-acute hospitalization. You will ensure efficient and needs-based skilled nursing stays, facilitating seamless transitions to home or community. Responsibilities include managing patient care, engaging with facility staff and providers, performing assessments, developing care plans, and identifying areas for process improvement. You will also actively participate in clinical huddles and meetings, and prepare reports on program success and patient outcomes. This role requires an Associate Degree in Nursing (ASN), a current RN license, and 3-5 years of experience in telephonic care management and skilled nursing facility care. Excellent communication, problem-solving, and organizational skills are essential. Evergreen offers a competitive salary, bonus eligibility, and a comprehensive benefits package.

Requirements

• Associate degree in nursing required (ASN); bachelor’s degree in nursing (BSN) preferred
• Current RN License required; Compact License preferred
• Minimum 3-5 years of experience in telephonic care management and skilled nursing facility care
• Knowledge of value-based care models and strategies to reduce readmissions
• Excellent communication, problem-solving and organizational skills
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• You have the 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

• Manage the overall care management of patient caseload by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations
• Facilitate seamless transitions for nephrology patients from a Skilled Nursing Facility to home or community
• Collaborate with hospital discharge planners, providers and SNF staff to ensure patients’ needs are addressed
• Monitor patient progress in skilled nursing facilities and identify barriers to timely discharge
• Actively participate in clinical huddles, IDT meetings, and patient care conferences for patients under your care management
• Develop and implement strategies to optimize length of stay while maintaining high-quality care
• Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with internal and external care team stakeholders
• Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey
• Perform assessments and identify the needs, including social determinants of health, of caseload patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans
• Identify and develop SNF stakeholders and foster relationships for communication and coordination of care
• Identify areas for improvement in post-acute care processes and share or implement evidence-based solutions
• Engage in continuous, organizational process improvement to identify opportunities and execute action plans to optimize care management workflows, patient engagement processes, customer/patient care efforts, and other protocols
• Prepare reports and other deliverables to communicate program changes or developments to appropriate stakeholders
• Collect 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

Preferred Qualifications

• Experience in kidney care and RAC-CT certification preferred
• Strong understanding of skilled nursing facility operations and regulations strongly preferred
• You have excellent working knowledge of community resources
• You can navigate ambiguity in an environment where full scope of information might not be available or might be delayed in coming
• You have experience in caring for people living with kidney disease, or a willingness to learn how to serve this unique population
• You have experience with team-based care and have excellent collaboration skills
• You have an exceptional capacity to multitask
• You are self-directed
• You have the tenacity required to drive initiatives forward, overcome obstacles, and achieve goals despite challenges

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