Nurse Care Manager

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:
• 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.
• Required Qualifications
• One of the two following qualifications is required in the state of Illinois :
• A Bachelor's degree in nursing (BSN) with an active RN license (compact license preferred where applicable) and/or;
• A Bachelor's or Master's degree in Physical Therapy with an active PT license
• Minimum 3-5 years of experience in telephoni

Requirements

• Your Role
• While this position is fully remote , you must be able to work 8:30am - 5pm in the Central or Eastern time zone.

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