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Evergreen Nephrology logo
Evergreen Nephrology

Empowering nephrologists to transform kidney care and improve patient outcomes

Nurse Care Manager – Post Acute, RN/PT

ManagerManagerOtherRemoteSeniorTeam 51-200H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

144 days ago

Salary

$90K - $103K / year

Seniority

Senior

Bachelor Degree3 yrs expEnglish

Job Description

Nurse Care Manager – Post Acute, RN/PT

Evergreen Nephrology

• Manage the overall care management of patient caseload by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations. • Facilitate seamless transitions for nephrology patients from a Skilled Nursing Facility to home or community. • Collaborate with hospital discharge planners, providers and SNF staff to ensure patients’ needs are addressed. • Monitor patient progress in skilled nursing facilities and identify barriers to timely discharge. • Actively participate in clinical huddles, IDT meetings, and patient care conferences for patients under your care management. • Develop and implement strategies to optimize length of stay while maintaining high-quality care. • Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with internal and external care team stakeholders. • Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey. • Perform assessments and identify the needs, including social determinants of health, of caseload patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans. • Identify and develop SNF stakeholders and foster relationships for communication and coordination of care. • Identify areas for improvement in post-acute care processes and share or implement evidence-based solutions. • Engage in continuous, organizational process improvement to identify opportunities 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. • Other duties consistent with this role, as assigned.

Job Requirements

  • Bachelor’s degree in nursing (BSN) with an active RN license or a Bachelor’s or Master’s degree in Physical Therapy with an active PT license; Compact License preferred where applicable
  • Minimum 3-5 years of experience in telephonic care management and post-acute care
  • Experience in Utilization Management and/or Utilization Review
  • Experience in specialty care including kidney care or related field
  • Excellent communication, problem-solving and organizational skills
  • Knowledge of value-based care models and strategies to reduce readmissions
  • Experience with team-based care and have excellent collaboration skills
  • Excellent working knowledge of community resources
  • Strong understanding of skilled nursing facility operations and regulations strongly preferred.
  • 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
  • Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
  • Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Benefits

  • 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 for eligible roles
  • A 401(k) program where Evergreen matches up to 4% of contributions
  • Paid parental leave
  • A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology

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