Nurse Care Manager - RN

Who You Are

You are devoted and compassionate, and enjoy being on the front lines of healthcare, changing the lives of your patients. You’re passionate about digging in to get to the root cause of a patient’s conditions, remove social determinants of healthcare, and ensure the highest possible quality of life and best outcomes for those in your care. You believe patients living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You don’t want to sacrifice quality over quantity, and you aim to provide the same level of care and commitment to your team and patients that you would to your own family member. You thrive in innovative and evolving environments with high rates of change. You are driven by process improvements. 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 and 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 Nurse Care Manager with Evergreen Nephrology, you will collaborate with a team of Physicians, Advanced Practice Providers, and interdisciplinary team members to manage an assigned patent panel and address patients’ specialized needs based on their individual conditions. Your job duties will include taking full ownership of patients within your panel, with an additional focus on helping patients with kidney disease navigate the kidney care continuum and manage all their additional chronic conditions. You will perform assessments to identify their needs based on their values, goals, and preferences. From this assessment, you will develop 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.

 Primary functions for the Nurse Care Manager include:

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• Quickly build empathetic relationships with patients and families
• Evaluate and identify patient’s needs based on their respective values, goals, and preferences, then translate these needs into clinical needs
• Interface with Nephrology Partners, Primary Care Physicians, Advanced Practice Providers, Specialists, and various disciplines on the development of case management plans/programs
• In conjunction with the Nephrologist partner/APP, implement care/treatment plan by coordinating access to health services across multiple providers/disciplines
• Monitor care and identify cost-effective measures, including recommendations for alternative levels of care and utilization of resources
• Effectively coordinate patient education (including family involvement as appropriate) regarding treatment options, and advocate for access to the preferred treatment option
• Monitor and evaluate the effectiveness of the case management plans based on quality and cost drivers and modifies as necessary
• Coordinate the interdisciplinary approach to providing continuity of care, including kidney disease progression management, utilization management, kidney care coordination, needed for outside services for patients/families
• Act as a clinical liaison, per their specialty, with outside agencies such as County CCS, non-plan facilities, outside providers, employers and/or workers' compensation carriers, and third-party administrators
• Prepare reports, communicate program changes to appropriate staff, and develop protocols in accordance with compliance requirements
• Coordinate and advocate for effective transition of care when appropriate/needed
• Engage internal resources to identify and respond to Social Determinants of Health such as lack of transportation, stable housing, or food resources
• Participate in the data collection, formulation and implementation, and monitoring of action strategies and outcomes of care or customer service
• Ensure that accurate records are maintained of the care associated with each patient