Evergreen Nephrology

• Consult directly with patients, their caregivers, and other members of their care team to implement Evergreen’s comprehensive pharmacy care management programs, including medication reconciliation, patient education, and collaboration with the patient’s care team to resolve medication concerns. • Utilize principles of Comprehensive Medication Management (CMM) to optimize all clinical aspects of medication therapy regimens, considering effectiveness of medications, identify unnecessary drug therapies, incomplete immunization records, medication safety, adverse effects, renal dose adjustments, and other contraindications. • Engage in patient outreach and consultation to support real-world adherence with the medication plan of care, integrating best practice techniques for behavior modification, to optimize patient health outcomes. • Drive medication-related clinical quality initiatives, including GDMT optimization and adherence improvement, by identifying gaps, designing targeted interventions, and partnering with care teams to improve patient outcomes and performance against value-based quality measures. • Participate in medication safety initiatives to minimize use of nephrotoxic medications among our CKD patient population and address other high-risk medication use with a holistic, patient-centered approach. • Support appropriate medication use across the continuum of care, focusing on the post-hospital discharge period, to ensure patients accurately implement the medication plan. • Seek alternatives as necessary to ensure the best care is provided that will maximize clinical outcomes, ensure equitable access to medications, and support appropriate levels of financial spend. • Analyze and recommend cost-savings strategies based on plan formularies, insurance phases, and evidence-based chronic disease management guidelines. • Act as an internal subject matter expert, developing and delivering education to patients, caregivers, and internal Evergreen teams regarding medications and chronic disease states. • Other duties consistent with this role, as assigned.

• Oversee the overall performance of Evergreen-aligned (EGA) patients across all markets and payers • In close dyad partnership with the Chief Clinical Officer, lead the buildout and growth of EPG as a scalable virtual care delivery model, ensuring the infrastructure, workflows, and team are positioned to expand across markets • Develop and deploy strategy to implement standardized quality programs that drive maximum performance and quality outcomes across all markets and payers • Own and manage the EGA P&L • Develop and maintain dashboards and reports to track KPIs; monitor performance and drive action plans to address gaps • Collaborate with key internal and external stakeholders to drive performance in overall engagement, documentation, quality, and total medical expense • Lead the ongoing management of value-based partnerships, including addressing payer issues and ensuring adherence to contractual obligations • Provide strategic and operational oversight of the PES function, ensuring the team is effectively reaching, engaging, and scheduling patients into care • Set clear productivity and performance expectations with KPI targets; drive accountability for team capacity utilization and outreach effectiveness, identifying and removing barriers to patient access. • Own and manage the PES program budget • Partner with clinical leadership to align outreach efforts with provider availability and evolving capacity needs • Partner with Marketing and Tech teams to develop and execute patient engagement campaigns that drive awareness, outreach effectiveness, and scheduling conversion • Continuously improve outreach models, workflows, and tools to scale PES operations as EPG grows • Manage, coach, and develop the EPG and PES teams, fostering a high-performance culture with clear expectations, regular feedback, and professional growth opportunities • Drive cross-functional collaboration across clinical, operations, quality, and technology teams to ensure alignment with organizational priorities and patient care goals. • Other duties consistent with this role, as assigned.

• The CKD RN Navigator is responsible for providing care coordination, education, and support to patients with chronic kidney disease (CKD) across various stages of the disease. • This role serves as a liaison between patients, families, nephrologists, primary care providers, and the interdisciplinary healthcare team to optimize patient outcomes, promote self-management, and ensure seamless transitions of care. • Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Care Coordinators, RN Educator, Dietitians, Pharmacists, Licensed Clinical Social Workers, and Psychiatrists. • You will take the lead on identifying care gaps and navigating the patient through their CKD to ESKD journey in collaboration with a Care Coordinator, RN Educator, and the primary Nephrologist. • You will play an essential role in helping patients achieve their goals through timely and proactive care planning toward a planned outpatient dialysis start with a permanent access or a care pathway of the patient’s choice driven by patient education and care team support.

• Lead and define statistical analyses to identify cost, utilization, and performance drivers across populations, markets, and payer arrangements. • Partner with data, actuarial, and analytics teams to validate healthcare claims data structures, ensure data is accurately represented in enterprise datasets, and resolve discrepancies affecting downstream reporting and analysis. • Apply economic insights to strengthen impact modeling and quantify the financial and operational implications of clinical and business initiatives. • Develop experimental designs for new program initiatives to ensure programs are set up for impact analysis in advance • Translate complex claims, reimbursement, and utilization data into clear, actionable recommendations for cross-functional stakeholders and senior leadership. • Identify trends, anomalies, and emerging opportunities within claims and performance data, and communicate their implications for value-based care strategy.

• The Community Health Worker (CHW) at Evergreen Nephrology supports high-quality, patient-centered care by providing exceptional patient service, care coordination, and connection to community-based resources. • This role serves as a trusted liaison between diverse, underserved, and vulnerable populations and the health and social service systems that support them, with a strong focus on building trust, engagement, and patient empowerment. • Working within an interdisciplinary care team including Nurse Practitioners, Nurse Care Managers, Care Coordinators, Dietitians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers, and Psychiatrists the CHW leverages Evergreen’s integrated technology platform to help patients access services aligned with their individual needs. • The CHW also partners with clinical teams and leadership to support community outreach initiatives designed to promote, maintain, and improve the health and well-being of patients and their families. • You will take the lead on comprehensive care coordination with a focus on identifying and addressing Social Determinants of Health while partnering with the interdisciplinary care team. • You will be an essential resource for patients, assisting them in navigating the healthcare system, accessing resources and support, and achieving better health outcomes.

• You are responsible for influencing and ensuring the best clinical care for patients through exceptional patient service and care coordination across disciplines. • Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Dieticians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers and Psychiatrists. • You will take the lead on comprehensive care coordination with a focus on identifying and addressing Social Determinants of Health while partnering with the interdisciplinary care team. • You will be an essential resource for patients, assisting them in navigating the healthcare system, accessing resources and support, and achieving better health outcomes.

• You are responsible for influencing and ensuring the best clinical care for patients through exceptional patient service and care coordination across disciplines. • Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Dieticians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers and Psychiatrists. • You will take the lead on comprehensive care coordination with a focus on identifying and addressing Social Determinants of Health while partnering with the interdisciplinary care team. • You will be an essential resource for patients, assisting them in navigating the healthcare system, accessing resources and support, and achieving better health outcomes.

• Serve as Evergreen’s primary learning leader and builder • Own the design and delivery of business-critical learning priorities • Focus on enabling execution and ensuring teams perform effectively • Personally design, build, and deliver Evergreen’s highest-impact learning programs • Act as a key learning partner to Clinical Operations leadership • Prioritize learning investments based on Clinical Operations needs • Define and track success using a combination of learning adoption and engagement

• Conduct monthly clinical check-ins, identifying and addressing clinical concerns • Reinforce care plans, escalating issues appropriately • Ensure clinical documentation accuracy across both the EHR and partner technology platform • Build strong, ongoing relationships with patients and caregivers through regular outreach • Conduct structured symptom assessments (pain, fatigue, neuropathy, SOB, nausea, etc.) • Evaluate changes in condition using licensed clinical judgment • Assess medication adherence issues, side effects, or confusion about regimen • Identify clinical red flags requiring escalation (e.g., worsening symptoms, new SOB, uncontrolled pain, concerning vitals) • Collaborate with the provider team on symptom changes, new concerns, or medication-related issues • Document all patient interactions clearly in both the EHR and CCM patient management platform • Track and log qualifying CCM time accurately for billing compliance

• Support CCM patient enrollment and onboarding activities. • Verify eligibility based on Evergreen and payer program guidelines. • Ensure patient consent documentation is completed prior to outreach. • Proactively maintain patient engagement regularly. • Identify inactive or non-engaged patients and escalate appropriately. • Conduct text & telephonic outreach to enrolled CCM patients weekly. • Achieve required engagement time standards aligned with Medicare CCM billing requirements. • Support achievement of required engagement time for billing compliance. • Reinforce provider-directed care plans during patient interactions. • Identify barriers to adherence including medication access, transportation, or social needs. • Document patient interactions accurately within the CCM patient management platform and EHR systems. • Track engagement time consistent with Medicare CCM billing requirements. • Maintain audit-ready documentation standards. • Ensure HIPAA and PHI compliance. • Facilitate patient access to their referring provider and clinical staff. • Support care transitions following hospitalizations or ED visits. • Coordinate referrals and follow-up appointments. • Escalate symptom concerns or medication issues to licensed clinical staff. • Utilize CCM platform and EHR systems daily. • Manage patient messaging workflows. • Collaborate with remote clinical and operational teams.