This position requires a CA RN license and will support the Pacific Time Zone. We are currently offering a $5000 sign on bonus!
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 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
The Nurse Care Manager is responsible for collaborating with a team of Physicians, Advanced Practice Providers, and Interdisciplinary Team members to manage an assigned patient 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 their additional chronic conditions. You will perform assessments to identify needs based on individual 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.
While this position will primarily support patients in the San Diego, CA market, it can be a remote role for anyone within the state of CA.
PRIMARY FUNCTIONS
- Quickly build trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration in their care journey
- Assess and identify the needs of Evergreen patients and caregivers based on values, goals and preferences, translating these into patient centric actionable care plan
- Adhere to workflow best practices by ensuring consistent application of the workflow to streamline care management processes, improve patient outcomes and maintain compliance
- Follow evidence-based care management guidelines and deliver high quality, patient-centered care aligned with Evergreen Nephrology’s goals and metrics
- Collaborate with Nephrology Partners, Primary Care Physicians, Advanced Practice Providers, Specialists, and various disciplines to create and implement integrated care plans
- Coordinate care across multiple providers and disciplines to ensure timely access to health services, while ensuring the patient is compliant with the nephrologist/primary care team’s treatment plan
- Conduct telephonic triage assessments to evaluate patients' needs
- Build trust with patients and clinical care team members through exceptional omnichannel customer service
- Actively listen during patient conversations to activate personalized support for patients and provide appropriate next steps for care planning
- Monitor care and identify cost-effective measures, including recommendations for alternative levels of care and utilization of resources
- Facilitate patient and family/caregiver education on treatment options, advocating for the preferred treatment option so patients can make informed decisions
- Continuously monitor and evaluate the effectiveness of care management plans, modifying interventions as necessary to align with Evergreen’s quality and cost metrics
- Coordinate the interdisciplinary approach to providing continuity of care, including kidney disease progression management, utilization management, and kidney care coordination needed for outside services for patients/families
- Act as a clinical liaison for external agencies such as County CCS, non-plan facilities, outside providers, employers and/or worker’s compensation carriers, and third-party administrators to ensure stakeholders are aligned with patient care plans
- Prepare reports, communicate program changes to appropriate staff, and develop protocols in accordance with compliance requirements
- Ensure seamless transitions of care by coordinating and advocating for patients as they move between care settings, proactively addressing potential barriers and collaborating with the multidisciplinary team to ensure continuity of care, reduce readmissions and promote optimal health outcomes
- Leverage internal and external resources to identify and address SDOH needs and ensure patients have access to necessary support for improved health outcomes
- Participate in the data collection, formulation and implementation, and monitoring of action strategies and outcomes of care or customer service
- Ensure accurate records are maintained of the care associated with each patient
- Interpret regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies
- Actively participate in huddles, IDT sessions, and patient case conferences
- Commendably represent Evergreen to patients, their families, and the community
- Regular and reliable attendance
- Other duties as assigned, including cross market coverage as needed
HOW YOU QUALIFY
- You accept that things change quickly in a startup environment and are willing to pivot rapidly on priorities
- Associate in Nursing Degree required
- Current RN License is required, Compact License preferred
- Care management experience required
- Certified Case Manager preferred
- Chronic and complex care management strongly preferred
- 1 year of utilization management experience preferred
- Experience in specialty care including kidney care preferred
- 3 years of clinical practice in a hospital, clinic, physician office, home care, or nursing home setting preferred
- Ability to work in a remote work environment
- At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wired to the house internet (Cable, Fiber, or DSL) and hardwired to the internet device is recommended
- Evergreen will provide Remote or Hybrid Home/Office employees with telephony applications and equipment to meet the business requirements for their position/job
- Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
HOW YOU’RE SUPPORTED
- You will benefit from Evergreen Nephrology’s exceptional total rewards package, including competitive base pay with bonuses, paid time off starting at four weeks for full-time employees, 12 paid holidays per year, reimbursement for continuing medical education, 401k with match, health, dental, and vision insurance.
- We are proud to offer family-friendly policies that support paid parental leave and flexible work arrangements.
- We commit to a robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology.
- As an inclusive and diverse team, you will collaborate with like-minded healthcare professionals who, like you, understand the importance and value of Evergreen Nephrology’s high-quality, value-based care model.
Contact Information
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