Nurse Care Manager

November 17

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Evergreen Nephrology

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Healthcare Insurance • Pharmaceuticals

Evergreen Nephrology is a company focused on transforming kidney care by empowering nephrologists to provide high-quality and personalized care to patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). By putting nephrologists at the forefront, the company provides them with financial backing, interdisciplinary clinical resources, analytical insights, and technology-enabled tools to improve patient outcomes and experience. Evergreen Nephrology collaborates with strategic partners to address healthcare challenges, including disparate electronic health records (EHRs), transplantation process visibility, and patient readmission risks. The company's co-founders, Adam Boehler and Abe Sutton, have been recognized for their contributions to kidney care models and organ procurement standards, reflecting a deep commitment to improving kidney care quality nationwide.

51 - 200 employees

⚕️ Healthcare Insurance

💊 Pharmaceuticals

💰 $4.3M Venture Round on 2022-06

📋 Description

• 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 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 through comprehensive evaluations. • 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.

🎯 Requirements

• Associate degree in nursing • Current RN License is required, Compact License preferred • Care management experience required • Certified Case Manager 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

• 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