Nurse Care Manager

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Oversee the comprehensive care management of a patient caseload by utilizing your experience, expertise, and knowledge in nursing and value-based care operations.

• Ensure smooth transitions for nephrology patients from a Skilled Nursing Facility to their home or community.

• Work in collaboration with hospital discharge planners, providers, and SNF staff to address patients’ needs effectively.

• Track patient progress in skilled nursing facilities and identify obstacles to timely discharge.

• Actively engage in clinical huddles, IDT meetings, and patient care conferences for those under your management.

• Create and execute strategies to enhance length of stay while ensuring high-quality care.

• Facilitate smooth transitions of care as patients move across different care settings, proactively resolving potential obstacles and working with both internal and external care team stakeholders.

• Build trusting relationships with patients and their families to provide clinical and emotional support, fostering collaboration throughout their care journey.

• Conduct assessments to identify the needs of caseload patients and caregivers, including social determinants of health, and translate these into actionable, patient-centric care plans based on values, care goals, and individual preferences.

• Identify and cultivate relationships with SNF stakeholders to enhance communication and coordination of care.

• Recognize opportunities for improvement in post-acute care processes and share or implement evidence-based solutions.

• Participate in continuous organizational process improvement efforts to identify opportunities and execute action plans aimed at optimizing care management workflows, patient engagement processes, customer/patient care efforts, and other protocols.

• Prepare reports and other documentation to inform relevant stakeholders about program changes or developments.

• Gather data to compile and present reports alongside program leaders on program success, patient outcomes, and patient/caregiver satisfaction.

• Perform additional duties consistent with this role as assigned.

⛳️ Requirements

• One of the following qualifications is required in the state of Illinois:

• A Bachelor’s degree in nursing (BSN) with an active RN license (compact license preferred where applicable) and/or;

• A Bachelor’s or Master’s degree in Physical Therapy with an active PT license.

• A minimum of 3-5 years of experience in telephonic care management and post-acute care.

• An active license in good standing in the state of Illinois.

• Experience in Utilization Management and/or Utilization Review.

• Background in specialty care including kidney care or a related field.

• Exceptional communication, problem-solving, and organizational skills.

• Understanding of value-based care models and strategies to minimize readmissions.

• Experience in team-based care with excellent collaboration skills.

• Strong knowledge of community resources.

• A solid understanding of skilled nursing facility operations and regulations is strongly preferred.

• Intermediate proficiency with MS Office Suite products, including Outlook and Teams.

• Ability to work effectively in a primarily remote environment:

• Home internet must meet a minimum download speed of 25 Mbps and upload speed of 10 Mbps. A hardwired connection via Cable, Fiber, or DSL is recommended.

• Evergreen will provide remote employees with telephony applications and equipment necessary for their business role.

• Employees must have a dedicated workspace free from ongoing interruptions to safeguard member PHI / HIPAA information.

🏝️ Benefits

• Paid time off beginning at 4 weeks for full-time employees.

• 12 paid holidays each year.

• Medical, dental, vision, and life insurance, including an HSA with employer match.

• Reimbursement for continuing medical education for eligible positions.

• A 401(k) plan where Evergreen matches up to 4% of contributions.

• Paid parental leave.

• A comprehensive training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology.