Evergreen Nephrology

Manager

• Work with the Senior Director of the Evergreen Compassionate Care Program (ECCP).
• Manage the healthcare journey of patients referred to the program.
• Collaborate with Physicians, Advanced Practice Providers, and interdisciplinary team members.
• Perform assessments and advance care planning conversations.
• Refer patients to appropriate programs or coordinate continued care.
• Act as a clinical liaison and educator regarding advance care planning and hospice care.

Nurse Care Manager – Compassionate Care Program

Director

• Lead the operational delivery of the PAC program across assigned markets so that patients moving from hospital to SNF and from SNF to home receive coordinated care
• Build and maintain strong SNF partnerships, standard clinical performance expectations, and clear escalation paths to resolve barriers to care. Understand and lead escalation pathways and communication with nephrologist and practices
• Ensure consistent, reliable execution of PAC workflows including SNF engagement, identification in hospital, SNF admission review, care plan alignment with nephrologist, length-of-stay management, discharge readiness, patient benefit and coordination with CM teams such as EG Compassionate Care and CCPM programs
• Lead, coach, and develop the PAC clinical team
• Track and report KPIs and outcomes such as SNF length of stay, time to first post-discharge visit, readmissions, avoidable ED use, patient experience, and program reach
• In collaboration with senior leadership, use data to identify trends and close gaps in quality of care and meet Evergreen’s KPIs and productivity measures for the PAC team
• Partner across all departments to ensure smooth handoffs, integrated care. Ensure compliance with CMS and payer requirements and support readiness for audits and accreditation activities
• Contribute to Evergreen’s culture of learning, iteration, and rapid improvement
• Other duties consistent with this role, as assigned

Director, Clinical Excellence – Post Acute, VBC

• 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 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 through comprehensive evaluations.
• 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 – Licensed MI, MN

• Oversee the delivery of Post Acute Care (PAC) Program to ensure seamless patient transitions from inpatient facilities to SNFs and from SNFs to home, improving patient outcomes and quality of life
• Design and deliver on the post-acute care delivery strategy for all attributed Evergreen patients, based on evidence-based practices and clinical guidelines to improve patient outcomes and ensure consistency in care management delivery
• Establish and monitor Key Performance Indicators to measure the effectiveness of post-acute care initiatives
• Accountable for achieving outcomes that reduce cost of care and improve clinical outcomes
• Use data and analytics to identify trends, gaps, and opportunities for improvement
• Create systems, structure and process to monitor appropriate level of care and care planning in SNF setting and intervene where necessary
• Identify and allocate essential resources efficiently
• Drive optimal performance of the PAC clinical team
• Direct the PAC clinical team’s engagement with SNFs
• Accountable for achieving outcomes that reduce cost of care and improve clinical outcomes
• Proactive monitor and manage team performance, ensuring specific and real-time feedback, in alignment with Evergreen’s performance management philosophy
• Coach up and support team member growth and development
• Inspire and influence team to deliver the best-in-class care our patients deserve, close clinical gaps, and escalate barriers to you quickly
• Drive patient engagement and involvement in their own care
• Develop and implement strategies to engage patients in their care
• Promote patient education and self-management to improve health outcomes and reduce utilization
• Implement patient feedback mechanisms and a process to address feedback
• Collaborate with key internal and external stakeholders to ensure aligned, high-quality PAC care delivery
• Develop strong partnership strategy, systems and processes with SNF facilities to ensure optimal collaboration and to, gather feedback, and help to align clinical pathways to eliminate barriers to care and achieve optimal clinical quality
• Partner with CMO, central clinical teams, learning and development, and operational leadership to roll out clinical education & training that supports the care management and quality program goals and standards
• Collaborate with the technology and population health operations team to ensure clinical excellence as we operationalize clinical pathways, workflows, and processes; set goals for clinical excellence to drive high quality and reliability in care
• Stay up-to-date on regulatory changes and industry trends, and incorporate into strategy and care delivery as needed
• Ensure compliance with CMS and payer rules and regulations
• Stay current with industry trends and best practices in post-acute care management and incorporate innovative approaches to enhance care delivery and achieve better health outcomes
• Other duties consistent with this role, as assigned.

Senior Director, Clinical Excellence – Post Acute, VBC

Data Engineer

• Design and scale Databricks-based data platform to support analytics and AI
• Build robust data pipelines and model multi-source healthcare data (claims, EMR/EHR, HIE, HIN)
• Architect, develop, and maintain Databricks-based data pipelines to integrate healthcare data (claims, clinical, operational)
• Design and implement scalable data models and subject-area data marts
• Implement data quality, lineage, security, and compliance frameworks
• Optimize platform performance, reliability, and cost efficiency
• Mentor and guide data engineers, setting coding standards and best practices
• Lead technical decisions and partner with analytics, product, and business stakeholders to deliver data solutions
• Collaborate with analytics, product, and business teams to deliver data solutions
• Perform other duties consistent with this role, as assigned

Senior Data Engineer

Operations

• Serve as the main project manager for onboarding new Nephrology Partners
• Define project scope and create and maintain project plans that drive projects to completion
• Function as the key stakeholder and single point of contact in the implementation and onboarding process
• Translate Value Based Care operational and clinical model to engage internal and external stakeholders
• Track performance and identify opportunities for improvement in partnership with Clinical Operations leaders
• Coordinate across Business Operations, Growth, Market Operations, Clinical Operations, Coding and Documentation Improvement, Quality, Tech, and Reporting/Analytics
• Work directly with Nephrology Partners to review project status, action items, and resolve issues
• Communicate and manage tasks with internal Evergreen team members related to partner implementations
• Maintain real time project status through online project management tools
• Establish and manage aggressive timelines and confront critical-path items and deadlines
• Provide weekly/monthly reporting and forecasting to management and Market Operations stakeholders
• Travel to client sites to provide support during go-lives (up to 50%) and build relationships as needed
• Support operating teams and SVP of Market Operations with documentation and structured approaches to phased customer rollouts
• Evolve Evergreen’s Implementation Playbook to standardize quality, efficiency and effectiveness across implementations

Nurse Care Manager – Compassionate Care Program

Director, Clinical Excellence – Post Acute, VBC

Nurse Care Manager – Licensed MI, MN

Senior Director, Clinical Excellence – Post Acute, VBC

Senior Data Engineer

Market Operations Implementation Director, VBC