Nurse Care Manager – Transitions of Care
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
- 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.
Requirements
- Associate Nursing degree with an active RN license (compact license preferred)
- 3+ years of care management experience
- 2+ years of Transitions of Care experience
- Chronic and complex care management experience
- Utilization management experience
- 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
- Paid time off starting at 4 weeks for full-time employees
- 12 paid holidays per year
- Medical, dental, vision and life insurance, including an HSA with employer match
- Reimbursement for continuing medical education for eligible roles
- A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure
- Paid parental leave
- A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
care managementtransitions of carechronic care managementcomplex care managementutilization managementpatient assessmentscare plan managementevidence-based care managementpatient educationdata collection
Soft Skills
empathyadvocacycollaborationcommunicationproblem-solvingorganizational skillspatient engagementrelationship buildingprocess improvementteamwork
Certifications
Associate Nursing degreeactive RN licensecompact license