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 Evergreen Compassionate Care Program (ECCP) to provide person-centered, holistic care. Responsibilities include conducting patient assessments, advance care planning, and coordinating care transitions. You will also educate internal and external partners on advance care planning and hospice care. This role requires strong clinical skills, experience in palliative care, and the ability to work effectively in a remote environment. Evergreen offers a competitive compensation package, including benefits such as paid time off, health insurance, and a 401(k) match.

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
• 1+ years of utilization management experience
• Certified Care Manager experience

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