Evergreen Nephrology

Manager

• Managing the overall care management of patient panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations.
• Establishing trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
• Serving as an advocate and community liaison for patients to ensure proper and timely resources and support while navigating the health care system after hospitalization and maintaining compliance with the primary care team’s/nephrologist’s treatment plan.
• Performing assessments and identifying the needs, including social determinants of health, of panel patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans.
• Ensure timely follow-up appointments, medication reconciliation, and referrals to necessary services.
• Coordinating the interdisciplinary approach to achieving continuity of care and reducing fragmentation, focusing on kidney disease progression management, utilization management, and provider coordination through active care plan management.
• Monitoring and evaluating the effectiveness of care management plans regularly, modifying interventions as necessary.
• Following evidence-based care management guidelines and established workflow protocols to deliver high quality, efficient, patient-centered care that aligns with Evergreen’s goals, quality metrics, and regulatory and payer requirements.
• Collaborating with physician partners, community providers, APPs, and other clinical disciplines to create, implement, and manage integrated care plans.
• Identifying cost-effective measures for patients that support value-based care goals of improving patient outcomes and quality while effectively managing resource utilization.
• Facilitating patient and caregiver education on treatment options and empowering patients to make informed decisions about their care.
• Supporting seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with IDTs.
• Actively participating in clinical huddles and patient care conferences for patients under your care management as needed.
• Engaging in continuous, organizational process improvement to identify opportunities for improvement 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 changes or developments to appropriate stakeholders.
• Collecting 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.

Nurse Care Manager

Program Manager

• Leading the day-to-day execution of Evergreen’s clinical quality programs
• Managing the performance of Quality Improvement Specialists (QIS) and related quality roles
• Ensuring consistent execution of quality workflows
• Driving accountability for care gap closure
• Supporting performance improvement across HEDIS, Medicare Stars, CKCC, and other value-based care programs
• Ensuring that frontline operations align with NCQA accreditation standards
• Overseeing documentation practices, workflow adherence, and compliance
• Coordinating resources and support teams to meet program deadlines and deliverables

Quality Program Manager

Recruitment

• Establish an end-to-end recruitment plan for assigned positions, including identifying, interviewing and presenting qualified candidates to leadership
• Determine applicant qualifications by analyzing responses during initial interview utilizing the job description
• Provide regular reports and feedback to leadership on candidate movement and pipeline health
• Proactively maintain candidate and job status in Greenhouse ATS
• Collaborate with hiring managers in a consultative approach to identify the right talent profile for the role and assist in creating job descriptions
• Build and maintain rapport and trust both internally and externally
• Build strong relationships with leadership by facilitating clear and confident conversations
• Execute an exceptional candidate experience throughout their time in the interview process with strong communication and compassion
• Partner with the Lead TA Partner, People Operations and Hiring Managers on offer creation, approval, and extension
• Other duties consistent with this role, as assigned

Talent Acquisition Partner – Temporary Role

Learning and Development

• Responsible for designing and developing high-impact training for our organization.
• Partner with our clinical educator and other subject matter experts across all teams to create meaningful learning experiences for our team members.
• Ensure that all learning designs are evidence-informed, scalable, and learner-centric.
• Be the primary administrator for our Learning Management System, handling tasks such as uploading and testing learning content, overseeing assignments, and preparing reports.
• Conduct appropriate analyses to identify skill and knowledge gaps to improve performance on the job.
• Oversee orientation and onboarding logistics and assist in facilitation of new hire onboarding.
• Design, develop and manage annual compliance training processes in partnership with Legal & Compliance teams.
• Collaborate with the Clinical Educator and other SMEs to design engaging and meaningful learning experiences for a variety of roles and clinical programs.
• Serve as a thought partner to leaders and SMEs to influence learning design, rollout, and reinforcement strategies.
• Design learning experiences for leadership development, role-based training, new team member onboarding, AI utilization, and other programs/initiatives, as needed.
• Design and develop elearning courses, microlearning, and assessments.
• Design and develop performance support materials (e.g. job aids, reference guides, toolkits).
• Leverage LinkedIn Learning to support ongoing education and training initiatives.
• Measure training effectiveness through learner feedback, assessments, and performance outcomes.
• Ensure learning content meets organizational, regulatory, and accreditation standards.
• Partner with SMEs to regularly review and refresh content as roles, tools, or regulations evolve.
• Support continuous improvement of all learning and development programs and initiatives.

Evergreen Nephrology

Nurse Care Manager

Quality Program Manager

Talent Acquisition Partner – Temporary Role

Learning and Development Specialist

Nurse Care Manager – Transitions of Care