Nurse Care Manager

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

📋 Description

• Overseeing the comprehensive care management of a patient panel by utilizing expertise and knowledge in nursing and value-based care operations.

• Building trusting and compassionate relationships with patients and their families to deliver clinical and emotional support while fostering collaboration throughout their healthcare journey.

• Acting as an advocate and community liaison for patients, ensuring access to appropriate resources and support as they navigate the healthcare system post-hospitalization while adhering to the treatment plans established by the primary care team and nephrologist.

• Conducting assessments to identify the needs of panel patients and caregivers, including social determinants of health, based on values, care goals, and individual preferences, and converting these into actionable, patient-centered care plans.

• Ensuring timely follow-up appointments, medication reconciliation, and necessary service referrals.

• Coordinating an interdisciplinary approach to maintain continuity of care and decrease fragmentation, emphasizing kidney disease progression management, utilization management, and provider coordination through active care plan management.

• Regularly monitoring and evaluating the effectiveness of care management plans and adjusting interventions as needed.

• Adhering to evidence-based care management guidelines and established workflow protocols to provide high-quality, efficient, patient-centered care that aligns with Evergreen’s objectives, quality metrics, and regulatory and payer requirements.

• Collaborating with physician partners, community providers, APPs, and other clinical disciplines to design, implement, and manage integrated care plans.

• Identifying cost-effective strategies that support value-based care goals aimed at enhancing patient outcomes and quality while efficiently managing resource utilization.

• Facilitating education for patients and caregivers regarding treatment options, empowering them to make informed decisions about their care.

• Supporting seamless transitions of care as patients move across various care settings, proactively addressing potential barriers and working alongside interdisciplinary teams.

• Actively participating in clinical huddles and patient care conferences for patients under your management as required.

• Engaging in ongoing organizational process improvement to pinpoint enhancement opportunities 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 updates or developments to relevant stakeholders.

• Collecting data to formulate and present reports with program leaders on program effectiveness, patient outcomes, and patient/caregiver satisfaction.

• Undertaking other duties consistent with this role as assigned.

⛳️ Requirements

• Associate Nursing degree with a valid RN license (compact license preferred).

• A minimum of 3 years of care management experience.

• At least 2 years of experience in Transitions of Care.

• Experience in chronic and complex care management.

• Familiarity with utilization management.

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

• Ability to work effectively in a predominantly remote environment: Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. A hardwired connection through Cable, Fiber, or DSL to the internet device is recommended.

• Evergreen will provide remote employees with necessary telephony applications and equipment to fulfill the business requirements of their role.

• Employees are required to work from a dedicated space free from ongoing interruptions to protect member PHI / HIPAA information.

🏝️ Benefits

• Paid time off starting 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) program where Evergreen matches up to 4% of contributions after six months of employment.

• Paid parental leave.

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