Evergreen Nephrology
Healthcare
NurseCareManager
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Nurse Care Manager at Evergreen Nephrology. Skills: Care management, Transitions of Care, Chronic care management, Patient advocacy. Manage patient panel care. Establish trusting relationships”
What You'll Achieve.
Delay disease progression; Shift care to home; Accelerate kidney transplants; Improve patient outcomes; Improve quality of life; Achieve continuity of care; Reduce fragmentation; Manage kidney disease progression; Manage resource utilization; Improve patient outcomes; Improve quality; Manage resource utilization
Industry & Context.
Process improvement
Work 8:30am – 5pm CT, Dedicated workspace, No ongoing interruptions
What They're Looking For.
Must Have
Associate Nursing degree, Active RN license, 3+ years care management, 2+ years Transitions of Care, Chronic and complex care management, Utilization management experience, Intermediate MS Office Suite skills, Minimum 25 Mbps download speed, Minimum 10 Mbps upload speed
Nice to Have
Compact RN license preferred, Epic EHR experience, Cerner EHR experience, Meditech EHR experience, Allscripts EHR experience, McKesson EHR experience, athenahealth EHR experience
What You'll Do.
Manage patient panel care
Establish trusting relationships
Provide clinical support
Provide emotional support
Serve as patient advocate
Serve as community liaison
Ensure timely follow-up appointments
Perform medication reconciliation
Coordinate interdisciplinary approach
Monitor care plan effectiveness
Follow evidence-based guidelines
Follow workflow protocols
Collaborate with physician partners
Collaborate with community providers
Collaborate with APPs
Collaborate with clinical disciplines
Identify cost-effective measures
Facilitate patient education
Facilitate caregiver education
Support transitions of care
Address potential barriers
Participate in clinical huddles
Participate in patient care conferences
Engage in process improvement
Identify opportunities for improvement
How You'll Work.
Team & Collaboration
Interdisciplinary Team (IDT) members; Physicians; Advanced Practice Providers (APPs); JV partner clinicians; Network providers; Contracted vendors; Community-based services; Clinical disciplines
Full Job Description
Who We Are Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants. We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today. Who You Are You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change. Your Role As a Transitions of Care Nurse Care Manager, you are responsible for collaborating with a team of physicians, Advanced Practice Providers (APPs), and Interdisciplinary Team (IDT) members to manage an assigned patient panel and address each patient’s specialized needs based on their recent hospitalization. Your job duties will include taking full ownership of patient care management within your panel, with an additional focus on helping patients with kidney disease navigate the kidney care continuum and manage their chronic
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