Nurse Care Manager

Summary

Join Evergreen Nephrology as an Evergreen Compassionate Care Nurse Care Manager and collaborate with a team of healthcare professionals to manage the healthcare journey of patients with kidney disease. You will work closely with the Senior Director of the ECCP to provide person-centered, holistic care, focusing on patient education, advance care planning, and coordinating care across multiple disciplines. Responsibilities include performing assessments, developing care plans, and acting as a clinical liaison and educator. This role requires strong communication, critical thinking, and collaboration skills. Evergreen offers a competitive compensation package, including benefits and a supportive work environment.

Requirements

• Current RN License is required
• Experience having goals of care discussions and discussions regarding end-of-life care decisions required
• 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

• Quickly build empathetic relationships with patients and families
• Effectively complete patient education (including family involvement as appropriate) regarding diagnosis, prognosis, treatment options, and advocate for access to the preferred treatment option
• Evaluate and identify patient’s needs based on their respective values, goals, and preferences by completing advance care planning (ACP) including a goals of care (GOC) discussion, and then translate the needs into clinical needs
• Apply critical thinking skills to the analysis of the data collected
• Identify opportunities for improvement in palliation of symptoms and develop a plan of care collaboratively with the patient’s providers
• Engage internal resources to identify and respond to social determinants of health such as lack of transportation, stable housing, or food resources
• Actively participate in huddles, IDT sessions, and patient case conferences as appropriate
• Interface with Nephrology Partners, Primary Care Physicians, Advanced Practice Providers, Specialists, and various disciplines on the development of case management plans/programs
• Develop the plan of care with input from the patient/family, as a result of the goals of care discussion(s), and the interdisciplinary team
• Ensure that accurate records are maintained of the care associated with each patient
• Communicate and implement the plan of care in all settings, including with community palliative care and hospice providers
• Coordinating care and access to health services across multiple providers/disciplines (home health, palliative care, hospice, pastoral care and counseling, etc)
• Evaluate the ongoing progress toward appropriate outcomes and care transitions
• Reassess and revise the plan of care as needed in collaboration with patient/family through ongoing goals of care discussions, and input from the interdisciplinary team, and document appropriately
• Maintain current knowledge and competency of hospice and palliative care nursing
• Educate internal partners, and external partners in the community, about the ECCP and how to identify and refer patients to the program
• Commendably represent Evergreen to patients, their families, and the community

Preferred Qualifications

• BSN preferred
• 1+ years of utilization management experience preferred
• 3+ years of clinical practice in an intensive care unit, or a hospice or palliative care role
• Certified Care Manager experience preferred but not required

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 insurance
• Paid parental leave
• Flexible work arrangements
• Robust training and development program