Evergreen Nephrology partners with nephrologists and other providers to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care.
YOUR ROLE
As a Post Acute Nurse Care Manager, you are responsible for collaborating with Skilled Nursing Facilities to manage nephrology patients who are receiving skilled nursing care after an acute hospitalization. This role focuses on ensuring their skilled nursing stay promotes efficiency as well as meets their specialized needs based on their individual conditions with a coordinated plan to discharge to home or community. Your job duties will include taking full ownership of patient care management within your caseload, including engaging with Skilled Nursing Facility staff, providers, patients, and their caregivers. You will perform assessments to identify needs based on individual values, goals, and preferences.
While this position is remote, it will primarily support patients in the Mountain and Pacific Time Zones.
PRIMARY FUNCTIONS
- Manage the overall care management of patient caseload by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations.
- Facilitate seamless transitions for nephrology patients from a Skilled Nursing Facility to home or community.
- Collaborate with hospital discharge planners, providers and SNF staff to ensure patients’ needs are addressed.
- Monitor patient progress in skilled nursing facilities and identify barriers to timely discharge.
- Actively participate in clinical huddles, IDT meetings, and patient care conferences for patients under your care management.
- Develop and implement strategies to optimize length of stay while maintaining high-quality care.
- Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with internal and external care team stakeholders.
- Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
- Perform assessments and identify the needs, including social determinants of health, of caseload patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans.
- Identify and develop SNF stakeholders and foster relationships for communication and coordination of care.
- Identify areas for improvement in post-acute care processes and share or implement evidence-based solutions.
- Engage in continuous, organizational process improvement to identify opportunities and execute action plans to optimize care management workflows, patient engagement processes, customer/patient care efforts, and other protocols.
- Prepare reports and other deliverables to communicate program changes or developments to appropriate stakeholders
- Collect data to prepare and deliver reports alongside program leaders on program success, patient outcomes, and patient/caregiver satisfaction.
- Other duties consistent with this role, as assigned
HOW YOU QUALIFY
- You accept that things change quickly in an early-stage environment and are willing to pivot rapidly on priorities
- You can navigate ambiguity in an environment where full scope of information might not be available or might be delayed in coming
- You align with Evergreen’s purpose, principles, and practices, encapsulated in our Culture Code
- You have experience in caring for people living with kidney disease, or a willingness to learn how to serve this unique population
- You have experience with team-based care and have excellent collaboration skills
- You have excellent working knowledge of community resources
- You have an exceptional capacity to multitask
- You are self-directed
- You have the tenacity required to drive initiatives forward, overcome obstacles, and achieve goals despite challenges
- Associate in nursing degree required, bachelor’s degree in nursing (BSN) preferred.
Current RN License required; Compact License preferred. - Strong understanding of skilled nursing facility operations and regulations strongly preferred.
- Minimum 3-5 years of experience in telephonic care management and post-acute care
- Experience in specialty care including kidney care preferred.
- Excellent communication, problem-solving and organizational skills.
- Knowledge of value-based care models and strategies to reduce readmissions.
- Intermediate skills with MS Office Suite of products including Outlook and Teams
- You have the ability to work effectively in a primarily remote 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
- Team Members must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Pay range for this role is $90,000 to $103,000, with exact pay determined based on experience, education, demand for role, geographic location and other role-specific criteria.
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.
Evergreen Nephrology is an equal opportunity employer that is committed to inclusion and diversity. We take affirmative action to ensure equal opportunity for all applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, Veteran status, or other legally protected characteristics.
Evergreen Nephrology will not discriminate or retaliate against applicants who inquire about, disclose, or discuss their compensation or that of other applicants.
Evergreen Nephrology is committed to working with and providing reasonable accommodations to job applicants with physical or mental disabilities. Applicants with a disability who require a reasonable accommodation for any part of the application or hiring process should email us for assistance. Reasonable accommodations will be determined on a case-by-case basis.
Contact Information
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