Nurse Care Manager

Summary

Join Evergreen Nephrology as a Nurse Care Manager and make a difference in the lives of kidney disease patients. You will manage a patient panel, providing clinical and emotional support while collaborating with a multidisciplinary team. This fully remote position requires managing patient care, coordinating with providers, and advocating for patients' needs. You will leverage your nursing expertise and value-based care knowledge to develop and implement patient-centric care plans. The role involves data collection, reporting, and continuous process improvement. Evergreen offers a competitive salary, bonus eligibility, and a comprehensive benefits package.

Requirements

• Associate degree in nursing
• Current RN License is required, Compact License preferred
• Care management experience required
• Able to work from 8:30am – 5pm in any time zone you indicate interest in
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Able to work effectively in a primarily remote environment: Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
• Employees 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 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 through comprehensive evaluations
• 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
• Perform other duties consistent with this role, as assigned

Preferred Qualifications

Certified Case Manager

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