Nurse Care Manager – Post Acute, RN/PT
Evergreen Nephrology
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $90,000 - $103,000 per year
About the role
- 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.
Requirements
- Bachelor’s degree in nursing (BSN) with an active RN license or a Bachelor’s or Master’s degree in Physical Therapy with an active PT license; Compact License preferred where applicable
- Minimum 3-5 years of experience in telephonic care management and post-acute care
- Experience in Utilization Management and/or Utilization Review
- Experience in specialty care including kidney care or related field
- Excellent communication, problem-solving and organizational skills
- Knowledge of value-based care models and strategies to reduce readmissions
- Experience with team-based care and have excellent collaboration skills
- Excellent working knowledge of community resources
- Strong understanding of skilled nursing facility operations and regulations strongly 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
Benefits
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Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
nursingtelephonic care managementpost-acute careUtilization ManagementUtilization Reviewvalue-based care modelspatient assessmentscare plansdata collectionpatient outcomes
Soft Skills
communicationproblem-solvingorganizational skillscollaborationrelationship buildingemotional supportprocess improvementteamworkadaptabilitytrust building
Certifications
Bachelor’s degree in nursing (BSN)active RN licenseBachelor’s or Master’s degree in Physical Therapyactive PT licenseCompact License