Evergreen Nephrology

Pharmacist

• Consult directly with patients, their caregivers, and other members of their care team to implement Evergreen’s comprehensive pharmacy care management programs, including medication reconciliation, patient education, and collaboration with the patient’s care team to resolve medication concerns.
• Utilize principles of Comprehensive Medication Management (CMM) to optimize all clinical aspects of medication therapy regimens, considering effectiveness of medications, identify unnecessary drug therapies, incomplete immunization records, medication safety, adverse effects, renal dose adjustments, and other contraindications.
• Engage in patient outreach and consultation to support real-world adherence with the medication plan of care, integrating best practice techniques for behavior modification, to optimize patient health outcomes.
• Drive medication-related clinical quality initiatives, including GDMT optimization and adherence improvement, by identifying gaps, designing targeted interventions, and partnering with care teams to improve patient outcomes and performance against value-based quality measures.
• Participate in medication safety initiatives to minimize use of nephrotoxic medications among our CKD patient population and address other high-risk medication use with a holistic, patient-centered approach.
• Support appropriate medication use across the continuum of care, focusing on the post-hospital discharge period, to ensure patients accurately implement the medication plan.
• Seek alternatives as necessary to ensure the best care is provided that will maximize clinical outcomes, ensure equitable access to medications, and support appropriate levels of financial spend.
• Analyze and recommend cost-savings strategies based on plan formularies, insurance phases, and evidence-based chronic disease management guidelines.
• Act as an internal subject matter expert, developing and delivering education to patients, caregivers, and internal Evergreen teams regarding medications and chronic disease states.
• Other duties consistent with this role, as assigned.

Care Management Pharmacist

Operations

• Oversee the overall performance of Evergreen-aligned (EGA) patients across all markets and payers
• In close dyad partnership with the Chief Clinical Officer, lead the buildout and growth of EPG as a scalable virtual care delivery model, ensuring the infrastructure, workflows, and team are positioned to expand across markets
• Develop and deploy strategy to implement standardized quality programs that drive maximum performance and quality outcomes across all markets and payers
• Own and manage the EGA P&L
• Develop and maintain dashboards and reports to track KPIs; monitor performance and drive action plans to address gaps
• Collaborate with key internal and external stakeholders to drive performance in overall engagement, documentation, quality, and total medical expense
• Lead the ongoing management of value-based partnerships, including addressing payer issues and ensuring adherence to contractual obligations
• Provide strategic and operational oversight of the PES function, ensuring the team is effectively reaching, engaging, and scheduling patients into care
• Set clear productivity and performance expectations with KPI targets; drive accountability for team capacity utilization and outreach effectiveness, identifying and removing barriers to patient access.
• Own and manage the PES program budget
• Partner with clinical leadership to align outreach efforts with provider availability and evolving capacity needs
• Partner with Marketing and Tech teams to develop and execute patient engagement campaigns that drive awareness, outreach effectiveness, and scheduling conversion
• Continuously improve outreach models, workflows, and tools to scale PES operations as EPG grows
• Manage, coach, and develop the EPG and PES teams, fostering a high-performance culture with clear expectations, regular feedback, and professional growth opportunities
• Drive cross-functional collaboration across clinical, operations, quality, and technology teams to ensure alignment with organizational priorities and patient care goals.
• Other duties consistent with this role, as assigned.

Senior Director, Operations

Data Analyst

• Collaborate with business partners to gather business reporting and analytics requirements to drive operational and clinical efficiency
• Understand and validate the accuracy and quality of the data represented within analytics and reporting outputs
• Collaborate with Data Engineering and Advanced Analytics to transform raw data into desired metrics and insights
• Utilize visualization tools (e.g., PowerBI) to design and create analytics dashboards and operational reports
• Train end users on newly deployed dashboards/deliverables
• Support ongoing enhancements and maintenance of deployed dashboards/deliverables
• Manage internal and external timelines for data reporting
• Identify and track issues with reports, including defects in logic, data quality problems, and process errors
• Maintain documentation of existing reports and dashboards (KPI definitions, data sources, etc.)
• Other duties consistent with this role, as assigned.

Senior Analyst, Reporting & Analytics

Navigator

• The CKD RN Navigator is responsible for providing care coordination, education, and support to patients with chronic kidney disease (CKD) across various stages of the disease.
• This role serves as a liaison between patients, families, nephrologists, primary care providers, and the interdisciplinary healthcare team to optimize patient outcomes, promote self-management, and ensure seamless transitions of care.
• Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Care Coordinators, RN Educator, Dietitians, Pharmacists, Licensed Clinical Social Workers, and Psychiatrists.
• You will take the lead on identifying care gaps and navigating the patient through their CKD to ESKD journey in collaboration with a Care Coordinator, RN Educator, and the primary Nephrologist.
• You will play an essential role in helping patients achieve their goals through timely and proactive care planning toward a planned outpatient dialysis start with a permanent access or a care pathway of the patient’s choice driven by patient education and care team support.

RN Navigator – CKD

Principal

• Lead and define statistical analyses to identify cost, utilization, and performance drivers across populations, markets, and payer arrangements.
• Partner with data, actuarial, and analytics teams to validate healthcare claims data structures, ensure data is accurately represented in enterprise datasets, and resolve discrepancies affecting downstream reporting and analysis.
• Apply economic insights to strengthen impact modeling and quantify the financial and operational implications of clinical and business initiatives.
• Develop experimental designs for new program initiatives to ensure programs are set up for impact analysis in advance
• Translate complex claims, reimbursement, and utilization data into clear, actionable recommendations for cross-functional stakeholders and senior leadership.
• Identify trends, anomalies, and emerging opportunities within claims and performance data, and communicate their implications for value-based care strategy.

Principal, Medical Economics

Learning and Development

• Serve as Evergreen’s primary learning leader and builder
• Own the design and delivery of business-critical learning priorities
• Focus on enabling execution and ensuring teams perform effectively
• Personally design, build, and deliver Evergreen’s highest-impact learning programs
• Act as a key learning partner to Clinical Operations leadership
• Prioritize learning investments based on Clinical Operations needs
• Define and track success using a combination of learning adoption and engagement

Senior Manager, Learning & Development

QA Engineer

• Collaborate with internal partners to collect data and develop compliance documents/evidence for successful accreditation surveys
• Monitor and maintain comprehensive compliance documents and evidence to ensure successful accreditation survey and ensure adherence to NCQA standards
• Maintain up-to-date records
• Educate staff across the organization regarding accreditation standards and requirements
• Evaluate current practices and identify compliance gaps and recommend solutions to close gaps
• Prepare training materials, reports, and materials to support compliance
• Coordinate accreditation surveys and serve as a point of contact during surveys to ensure all requirements are met
• Act as subject matter expert, handling complex assignments, and may assist training/mentoring department staff
• Regular and reliable attendance
• Other duties consistent with this role, as assigned.

NCQA Accreditation Specialist

Manager

• 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.

Nurse Care 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.

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

Care Management Pharmacist

Senior Director, Operations

Senior Analyst, Reporting & Analytics

RN Navigator – CKD

Principal, Medical Economics

Senior Manager, Learning & Development

NCQA Accreditation Specialist

Nurse Care Manager

Nurse Care Manager

Quality Program Manager

Talent Acquisition Partner – Temporary Role