Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:

• Manage the overall care management of an assigned patient panel using clinical expertise, nursing knowledge, and value-based care principles.

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

• Serve as a patient advocate and community liaison, ensuring timely access to resources, support, and adherence to individualized treatment plans.

• Conduct comprehensive assessments, including social determinants of health, to identify patient and caregiver needs, goals, and preferences.

• Develop and maintain patient-centered care plans based on ongoing assessments and evaluations.

• Coordinate post-discharge follow-up, medication reconciliation, referrals, and care plan implementation with physicians, APPs, community providers, vendors, and other clinical disciplines.

• Coordinate interdisciplinary care to improve continuity, reduce fragmentation, and support seamless transitions across care settings.

• Monitor care plan effectiveness and modify interventions as needed to achieve desired outcomes.

• Follow evidence-based guidelines and established workflows to deliver high-quality care that meets organizational, regulatory, payer, and quality requirements.

• Identify cost-effective interventions and resources that improve outcomes and support responsible resource utilization.

• Educate patients and caregivers on treatment options, self-management strategies, and available resources to support informed decision-making.

• Participate in clinical huddles, interdisciplinary care conferences, and other patient care discussions as needed.

• Drive process improvement by identifying opportunities and implementing solutions to enhance care management workflows, patient engagement, transitions of care, and the patient experience.

• Prepare reports and communications related to program updates, outcomes, and performance.

• Collect, analyze, and report data on program performance, patient outcomes, quality measures, and patient/caregiver satisfaction.

• Other duties consistent with this role, as assigned.

Required Qualifications

• Associate Degree in Nursing.

• Current RN license required; compact license preferred.

• 3+ years of care management experience.

• Chronic and complex care management experience.

• 2+ years of Transitions of Care experience preferred.

• Utilization management experience preferred.

• Certified Case Manager preferred.
• Intermediate skills with MS Office Suite of products including Outlook and Teams

• Able to work effectively in a primarily remote environment:
  • Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
  • Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
  • Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Compensation

The pay range for this role is $90,000 to $103,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.

This role is also eligible for a quarterly bonus.

Benefits

Evergreen Nephrology’s total rewards program is designed to support you in and outside of work. You can expect:

• Paid time off starting at 4 weeks for full-time employees

• 12 paid holidays per year

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

• Reimbursement for continuing medical education for eligible roles

• A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure

• Paid parental leave

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

Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.

If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at .

Originally posted on Himalayas