Nurse Care Manager - Chronic & Complex Care Management

WHO YOU ARE 

You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change. Does this sound like you? If so, we should talk.

WHO WE ARE 

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.

We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients.

We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.

YOUR ROLE

As a Chronic Complex Patient Management 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 individual conditions. Your job duties will include taking full ownership of patient care management within your panel, with an additional focus on helping patients with kidney disease navigate the kidney care continuum and manage their chronic conditions. You will perform assessments to identify needs based on individual values, goals, and preferences, which informs your development comprehensive care plans for each member. These care plans will be used to coordinate patient care delivery with Evergreen and our JV partner clinicians, network providers, contracted vendors, and community-based services. 

This is a remote role, but it will support patients in both the Central and Eastern Time Zones.

PRIMARY FUNCTIONS

• 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 need