Care Coordinator, MA - CST

About the role

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.

Responsibilities

• Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:
• Patient Enrollment & Eligibility
• Support CCM patient enrollment and onboarding activities.
• Verify eligibility based on Evergreen and payer program guidelines.
• Ensure patient consent documentation is completed prior to outreach.
• Proactively maintain patient engagement regularly.
• Identify inactive or non-engaged patients and escalate appropriately.
• Patient Outreach & Engagement
• Conduct text & telephonic outreach to enrolled CCM patients weekly.
• Achieve required engagement time standards aligned with Medicare CCM billing requirements.
• Support achievement of required engagement time for billing compliance.
• Reinforce provider-directed care plans during patient interactions.
• Identify barriers to adherence including medication access, transportation, or social needs.
• Expected activities include:
• High-volume outbound patient calling and texting.
• Follow-up outreach attempts.
• Documentation & Billing Compliance
• Document patient interactions accurately within the CCM patient management platform and EHR systems.
• Track engagement time consistent with Medicare CCM billing requirements.
• Maintain audit-ready documentation standards.
• Ensure HIPAA and PHI compliance.
• Patient Care Coordination & Clinical Workflow
• Facilitate patient access to their referring provider and clinical staff.
• Support care transitions following hospitalizations or ED visits.
• Coordinate referrals and follow-up appointments.
• Escalate symptom concerns or medication issues to licensed clinical staff.
• Preferred experience includes:
• Chronic kidney disease patient populations.
• Dialysis patient coordination.
• Medication adherence monitoring.
• Kidney transplant or specialty referrals.
• Technology & Communication
• Utilize CCM platform and EHR systems daily.
• Manage patient messaging workflows.
• Collaborate with remote clinical and operational teams.
• Required Qualifications
• Certified Medical Assistant
• 1-3 years healthcare experience
• Chronic disease or nephrology experience is preferred.
• Strong clinical assessment, communication, and documentation skills.
• Comfortable working in two systems (EHR + CCM platform) simultaneously.
• Ability to manage a structured, metric-driven workflow with reliability.
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Able to work effectively in a primarily r

Requirements

• Your Role
• This role is outreach-driven and operationally focused, requiring strong organization, patient communication skills, and the ability to manage a high-volume patient panel. Experience supporting nephrology or CKD patient populations is strongly preferred.
• The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.
• While this position is fully remote , you must be able to work 8:00am - 5:00pm in the central time zone.

Benefits

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