Nurse Care Manager

Summary

Join Evergreen Nephrology as a Nurse Care Manager and make a real difference in the lives of kidney disease patients. This remote position, supporting the Pacific Time Zone, offers a $5,000 sign-on bonus and a competitive salary. You will collaborate with a multidisciplinary team to develop and implement comprehensive care plans, coordinating care across multiple providers. Responsibilities include patient assessments, care plan development, and communication with patients, families, and other healthcare professionals. A CA RN license and care management experience are required. Evergreen Nephrology provides a comprehensive benefits package, including paid time off, paid holidays, 401k matching, health insurance, and a robust training and development program.

Requirements

• Associate in Nursing Degree required
• Current RN License is required, Compact License preferred
• Care management experience required
• Ability to work in a remote work 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
• Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Responsibilities

• Collaborate with a team of Physicians, Advanced Practice Providers, and Interdisciplinary Team members to manage an assigned patient panel and address patients’ specialized needs based on their individual conditions
• Take full ownership of patients within your panel, with an additional focus on helping patients with kidney disease navigate the kidney care continuum and manage their additional chronic conditions
• Perform assessments to identify needs based on individual values, goals, and preferences
• Develop comprehensive care plans for each member
• Use these care plans to coordinate patient care delivery with Evergreen and our JV partner clinicians, network providers, contracted vendors, and community-based services
• Quickly build trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration in their care journey
• Assess and identify the needs of Evergreen patients and caregivers based on values, goals and preferences, translating these into patient centric actionable care plan
• Adhere to workflow best practices by ensuring consistent application of the workflow to streamline care management processes, improve patient outcomes and maintain compliance
• Follow evidence-based care management guidelines and deliver high quality, patient-centered care aligned with Evergreen Nephrology’s goals and metrics
• Collaborate with Nephrology Partners, Primary Care Physicians, Advanced Practice Providers, Specialists, and various disciplines to create and implement integrated care plans
• Coordinate care across multiple providers and disciplines to ensure timely access to health services, while ensuring the patient is compliant with the nephrologist/primary care team’s treatment plan
• Conduct telephonic triage assessments to evaluate patients' needs
• Build trust with patients and clinical care team members through exceptional omnichannel customer service
• Actively listen during patient conversations to activate personalized support for patients and provide appropriate next steps for care planning
• Monitor care and identify cost-effective measures, including recommendations for alternative levels of care and utilization of resources
• Facilitate patient and family/caregiver education on treatment options, advocating for the preferred treatment option so patients can make informed decisions
• Continuously monitor and evaluate the effectiveness of care management plans, modifying interventions as necessary to align with Evergreen’s quality and cost metrics
• Coordinate the interdisciplinary approach to providing continuity of care, including kidney disease progression management, utilization management, and kidney care coordination needed for outside services for patients/families
• Act as a clinical liaison for external agencies such as County CCS, non-plan facilities, outside providers, employers and/or worker’s compensation carriers, and third-party administrators to ensure stakeholders are aligned with patient care plans
• Prepare reports, communicate program changes to appropriate staff, and develop protocols in accordance with compliance requirements
• Ensure seamless transitions of care by coordinating and advocating for patients as they move between care settings, proactively addressing potential barriers and collaborating with the multidisciplinary team to ensure continuity of care, reduce readmissions and promote optimal health outcomes
• Leverage internal and external resources to identify and address SDOH needs and ensure patients have access to necessary support for improved health outcomes
• Participate in the data collection, formulation and implementation, and monitoring of action strategies and outcomes of care or customer service
• Ensure accurate records are maintained of the care associated with each patient
• Interpret regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies
• Actively participate in huddles, IDT sessions, and patient case conferences
• Commendably represent Evergreen to patients, their families, and the community
• Regular and reliable attendance
• Other duties as assigned, including cross market coverage as needed

Preferred Qualifications

• Certified Case Manager preferred
• Chronic and complex care management strongly preferred
• 1 year of utilization management experience preferred
• Experience in specialty care including kidney care preferred
• 3 years of clinical practice in a hospital, clinic, physician office, home care, or nursing home setting preferred

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