Nurse Care Manager

Summary

Join Evergreen Nephrology as a Transitions of Care Nurse Care Manager and collaborate with a team of healthcare professionals to manage a patient panel, focusing on post-hospitalization care for individuals with kidney disease. You will develop and implement comprehensive care plans, coordinate care delivery, and advocate for patients within the healthcare system. This remote role primarily supports patients in the Mountain Time Zone, with some support for Central and Pacific Time Zones. You will leverage your nursing expertise and knowledge of value-based care to manage patient care, build strong patient relationships, and ensure timely access to resources. The position requires an Associate's degree in nursing, a current RN license, and care management experience. Evergreen Nephrology offers a competitive compensation package, including benefits such as paid time off, paid holidays, 401k matching, and health insurance.

Requirements

• Associate in nursing degree required
• Current RN License is required
• Care management experience required
• 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 panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations
• Establish trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey
• Serve as an advocate and community liaison for patients to ensure proper and timely resources and support while navigating the health care system after hospitalization and maintaining compliance with the primary care team’s/nephrologist’s treatment plan
• Perform assessments and identify the needs, including social determinants of health, of panel patients and caregivers based on values, care goals, and individual preferences, and translate these into patient-centric actionable care plans
• Ensure timely follow-up appointments, medication reconciliation, and referrals to necessary services
• Coordinate 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
• Monitor and evaluate the effectiveness of care management plans regularly, modifying interventions as necessary
• Follow 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
• Collaborate with physician partners, community providers, APPs, and other clinical disciplines to create, implement, and manage integrated care plans
• Identify cost-effective measures for patients that support value-based care goals of improving patient outcomes and quality while effectively managing resource utilization
• Facilitate patient and caregiver education on treatment options and empower patients to make informed decisions about their care
• Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with IDTs
• Actively participate in clinical huddles, and patient care conferences for patients under your care management as needed
• Engage 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
• 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

• Compact License preferred
• Transitions of Care experience strongly preferred
• Chronic and complex care management strongly preferred
• 1 year of utilization management experience preferred
• 3 years of clinical practice in a hospital, clinic, physician office, home care, or setting preferred
• Intermediate skills with MS Office Suite of products including Outlook and Teams

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
• Robust training and development program