Nurse Care Manager, Transition of Care

Summary

Join Evergreen Nephrology as a Transitions of Care Nurse Care Manager and contribute to transforming kidney care through a value-based, person-centered approach. You will collaborate with a team of physicians, Advanced Practice Providers (APPs), and Interdisciplinary Team (IDT) members to manage an assigned patient panel and address their specialized needs following hospitalization. Your responsibilities include taking ownership of patient care management, helping patients navigate the kidney care continuum, performing assessments to identify needs, developing comprehensive care plans, ensuring timely follow-up appointments, coordinating interdisciplinary care, monitoring care plan effectiveness, collaborating with healthcare professionals, identifying cost-effective measures, facilitating patient education, supporting seamless transitions of care, participating in clinical huddles, engaging in process improvement, preparing reports, and collecting data for program success evaluation. This role requires an Associate in nursing degree, a current RN License, care management experience, and a strong understanding of chronic and complex care management. Preferred qualifications include transitions of care experience, utilization management experience, and clinical practice in a hospital, clinic, physician office, home care, or similar setting. Evergreen Nephrology offers a competitive compensation package, including base pay with bonuses, paid time off, paid holidays, reimbursement for continuing medical education, 401k with match, health, dental, and vision insurance, family-friendly policies, 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

Responsibilities

• Managing the overall care management of patient panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations
• Establishing trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey
• Serving 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
• Performing assessments and identifying the needs, including social determinants of health, of panel patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans
• Ensure timely follow-up appointments, medication reconciliation, and referrals to necessary services
• Coordinating 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
• Monitoring and evaluating the effectiveness of care management plans regularly, modifying interventions as necessary
• Following 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
• Collaborating with physician partners, community providers, APPs, and other clinical disciplines to create, implement, and manage integrated care plans
• Identifying cost-effective measures for patients that support value-based care goals of improving patient outcomes and quality while effectively managing resource utilization
• Facilitating patient and caregiver education on treatment options and empowering patients to make informed decisions about their care
• Supporting seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with IDTs
• Actively participating in clinical huddles and patient care conferences for patients under your care management as needed
• Engaging 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
• Preparing reports and other deliverables to communicate program changes or developments to appropriate stakeholders
• Collecting 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

• 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

• Pay range for this role is $90,000 to $103,000, with exact pay determined based on experience, education, demand for role, geographic location and other role-specific criteria
• You will benefit from Evergreen Nephrology’s exceptional total rewards package, including 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
• We are proud to offer family-friendly policies that support paid parental
• We commit to a robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology