Care Coordinator
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Job Description
Care Coordinator supporting Evergreen Nephrology’s value-based kidney-care model. Coordinating patient care, social-resource access, advocacy, and health-outcome improvement remotely.
Responsibilities:
- Perform telephonic outreach to enroll and engage patients identified for the clinical program
- Establish connection as the primary point of contact for enrolled patients
- Develop and implement care plans under the direction of the Nurse Care Manager
- Facilitate transitions of care across care settings and dialysis centers
- Update patient care plans to enhance care delivery and coordination
- Conduct patient assessments to identify social, economic, and environmental factors impacting health
- Recommend gap closures for inclusion in comprehensive care plans
- Connect members to housing assistance, transportation, food security, and community support resources
- Guide members in using health and social services and community-based organizations
- Advocate for members by identifying barriers to care and addressing inequities
- Communicate with patients, families, caregivers, and healthcare teams
- Document member interactions, assessments, and care plans according to organizational and regulatory requirements
- Provide educational resources and solutions to empower patients and families
- Perform other assigned duties, including cross-coverage between markets
Requirements:
- 3 years of experience in health care coordination, community health work, or similar healthcare related field
- Experience with team-based approach to care
- Excellent working knowledge of community resources
- Exceptional ability to prioritize and task-switch to meet needs of patients and overall care team
- Self-directed and motivated to resolve issues professionally and creatively
- Strong communication and teaching skills
- Intermediate skills with MS Office Suite of products including Outlook and Teams
- Ability to work effectively in a primarily remote environment
- Minimum download speed of 25 Mbps and upload speed of 10 Mbps
- Wired-to-the-house internet (Cable, Fiber, or DSL) and hardwired internet device recommended
- Dedicated workspace without ongoing interruptions to protect member PHI / HIPAA information
- Ability to work 8:30a - 5p PST and support patients in the Pacific Time Zone
Benefits:
- Bonus eligibility
- 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
- Fully remote work arrangement
- Evergreen will provide Remote or Hybrid Home/Office employees with telephony applications and equipment to meet the business requirements for their position/job
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