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Empowering nephrologists to transform kidney care and improve patient outcomes
Nurse Care Manager
Location
CST (UTC-6)
Posted
32 days ago
Salary
$90K - $103K / year
Seniority
Lead
No structured requirement data.
Job Description
Nurse Care Manager
Evergreen Nephrology
Role Description As a Transitions of Care Nurse Care Manager, you are responsible for collaborating with a team of physicians, Advanced Practice Providers (APPs), and Interdisciplinary Team (IDT) members to manage an assigned patient panel and address each patient’s specialized needs based on their recent hospitalization. Your job duties will include: - Taking full ownership of patient care management within your panel. - Helping patients with kidney disease navigate the kidney care continuum and manage their chronic conditions post hospitalization. - Performing assessments to identify needs based on individual values, goals, and preferences. - Developing comprehensive care plans for each member. - Coordinating patient care delivery with Evergreen and our JV partner clinicians, network providers, contracted vendors, and community-based services. While this position is fully remote, you must be able to work 8:30am – 5pm in the Central time zone. Role 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. - Serving as an advocate and community liaison for patients to ensure proper and timely resources and support. - Performing assessments and identifying the needs of panel patients and caregivers. - Ensuring timely follow-up appointments, medication reconciliation, and referrals to necessary services. - Coordinating the interdisciplinary approach to achieving continuity of care. - Monitoring and evaluating the effectiveness of care management plans regularly. - Following evidence-based care management guidelines and established workflow protocols. - Collaborating with physician partners, community providers, APPs, and other clinical disciplines. - Identifying cost-effective measures for patients that support value-based care goals. - Facilitating patient and caregiver education on treatment options. - Supporting seamless transitions of care as patients move between care settings. - Actively participating in clinical huddles and patient care conferences. - Engaging in continuous organizational process improvement. - Preparing reports and other deliverables to communicate program changes or developments. - Collecting data to prepare and deliver reports on program success, patient outcomes, and patient/caregiver satisfaction. - Other duties consistent with this role, as assigned. Qualifications - Associate Nursing degree with an active RN license (compact license preferred). - 3+ years of care management experience. - 2+ years of Transitions of Care experience. - Chronic and complex care management experience. - Utilization management experience. - Intermediate skills with MS Office Suite of products including Outlook and Teams. - Able to work effectively in a primarily remote environment. Requirements - 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. - Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Compensation The pay range for this role is $90,000 to $103,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors. This role is also eligible for a quarterly bonus. 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 after six months of tenure. - Paid parental leave. - A robust training and development program that starts with onboarding and continues throughout your career.
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