Evergreen Nephrology

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 – PAC, RN/PT

Program Manager

• Oversee day-to-day operations for the CCPM and TOC care management teams, ensuring efficient workflows, standardized processes, and consistent achievement of program goals.
• Ensure delivery of high-quality longitudinal chronic/complex care management and best-in-class transitions of care, including adherence to clinical pathways, protocols, and documentation standards.
• Continuously evaluate and improve the performance of CCPM and TOC programs and team members, consistent with Evergreen’s performance management philosophy.
• Develop and implement collaborative strategies to improve program performance and patient outcomes (e.g., chronic disease control, complication prevention, and reduced readmissions) while ensuring patient and provider partner satisfaction.
• Support newly hired CCPM/TOC team members through orientation and onboarding; provide ongoing training, coaching, and development for established team members.
• Perform regular call and documentation (chart) audits to support performance management and identify opportunities for continuous improvement.
• Prepare performance reports, dashboards (as applicable), and meeting materials for CCPM and TOC programs for internal and external audiences.
• Oversee TOC workflows that support timely post-discharge outreach, medication reconciliation support, follow-up appointment coordination, and issue escalation to reduce avoidable readmissions.
• Develop and foster relationships with key stakeholders (e.g., IDT members, market leaders, and other program leaders) to drive outcomes through collaboration and cross-program partnership across CCPM and TOC.
• Build and maintain effective communication strategies between Evergreen and market stakeholders to foster strong relationships that support improved patient outcomes, in collaboration with market leaders.
• Be a Culture Champion by cultivating a culture of high performance, transparency, trust, and collaboration.
• Other duties consistent with this role, as assigned.

Program Manager – Chronic and Complex Care Management, Transitions of Care

Clinical Operations

• CKD Navigation, PAC, ECCP, and future clinical program performance
• Ensure clinical programs align with VBC contract requirements
• Clinical program stabilization to drive performance and scale
• Serve as senior escalation point for program risks, performance gaps, and complex operational challenges
• Partner with our Central Quality leadership team to translate enterprise quality strategy into program-level execution, workflow design and front-line accountability
• Drive data integrity and reporting alignment across EG tech platforms and reporting systems
• Advance tech enabled, omni channel care delivery to improve pt engagement, documentation accuracy and measurable outcomes
• Own program level KPI performance with rapid cycle improvement methods to close performance gaps
• Build and develop high performing clinical leadership teams with clear role clarity, performance expectations and accountability structures
• Other duties consistent with this role, as assigned.

Vice President, Clinical Operations

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

Communications

• Partner with our media relations agency to support brand awareness and thought leadership initiatives
• Help develop and execute proactive media strategies, including press releases, announcements, and story opportunities
• Coordinate interviews, speaking opportunities, and thought leadership content
• Monitor and report on media coverage and industry trends
• Support reputation management efforts
• Own and manage the social media content calendar across channels
• Develop and schedule engaging content that supports brand awareness and thought leadership
• Partner with internal stakeholders to source content and stories
• Track performance and optimize content based on engagement insights
• Partner with executives and the People Team to plan and execute internal communications
• Develop clear and engaging messaging for company updates, initiatives, and announcements
• Partner with key stakeholders to develop and implement a provider engagement communications strategy
• Create targeted messaging and materials to support provider engagement initiatives
• Support ongoing engagement through campaigns, updates, and educational communications
• Ensure all communications reflect a consistent brand voice and message
• Help maintain and evolve messaging frameworks
• Serve as a brand steward across communication channels
• Track and report on communications performance and engagement
• Provide insights and recommendations for continuous improvement
• Other duties consistent with this role, as assigned.

Communications Manager

• As a Program Manager, Connected Care Program (CCP) with Evergreen Nephrology, you are responsible for Evergreen’s CCP operations on Fee For Service Chronic Care Management across multiple service provider accounts, overseeing a clinical team of 25–35 LVNs/LPNs and Care Managers.
• The PM owns: Staffing & span-of-control for large care teams
• KPI performance across multiple accounts
• Clinical workflow adherence
• Data hygiene
• Documentation quality
• Escalation oversight
• Client and provider partnership management
• Continuous improvement and operational scaling
• This is a high-accountability, metrics-driven, enterprise leadership role requiring exceptional operational discipline, clinical workflow insight, and the ability to create order and predictability across large, distributed care teams.