Nurse Care Manager – Compassionate Care Program
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Job Description
Nurse Care Manager coordinating person-centered kidney, palliative, and hospice care. Guiding patients through care decisions for Evergreen Nephrology’s value-based kidney care programs.
Responsibilities:
- Manage the healthcare journey of patients referred to the Evergreen Compassionate Care Program based on their healthcare needs, goals, and wishes
- Take full ownership of an assigned patient panel and help patients with kidney disease understand their diagnosis, prognosis, and available services
- Collaborate with physicians, advanced practice providers, and interdisciplinary team members
- Perform assessments and advance care planning, including goals-of-care discussions
- Assess patients for hospice appropriateness and hospice-mindedness
- Refer patients to appropriate Evergreen kidney care programs or coordinate continued nephrologist care
- Coordinate transitions to hospice care with community providers
- Act as a clinical liaison and educator for internal and external partners
- Build empathetic relationships with patients and families
- Provide patient and family education regarding diagnosis, prognosis, treatment options, and access to preferred treatment
- Analyze collected data and identify opportunities to improve symptom palliation
- Develop, implement, evaluate, and revise collaborative plans of care
- Address social determinants of health through internal resources
- Participate in huddles, interdisciplinary team sessions, and patient case conferences
- Coordinate care and access to services across multiple providers and disciplines
- Maintain accurate patient records and documentation
- Maintain current hospice and palliative care nursing knowledge and competency
- Educate partners about the ECCP and referral criteria
- Represent Evergreen Nephrology to patients, families, and the community
- Perform other duties consistent with the role as assigned
Requirements:
- Active RN license in good standing
- 3+ years of clinical practice in an intensive care unit, or a hospice or palliative care role
- Experience having goals of care discussions and discussions regarding end-of-life care decisions
- Ability to pivot quickly on priorities in a quickly changing startup environment
- Intermediate skills with MS Office Suite, including Outlook and Teams
- Ability to work effectively in a remote environment
- Minimum download speed of 25 Mbps and upload speed of 10 Mbps
- Wired-to-the-house internet connection recommended, using Cable, Fiber, or DSL
- Dedicated workspace without ongoing interruptions to protect PHI/HIPAA information
- CHPN certification preferred
- Compact RN licensure preferred
- BSN preferred
- 1+ years of utilization management experience preferred
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
- 401(k) program with Evergreen matching up to 4% of contributions after six months of tenure
- Paid parental leave
- Robust training and development program from onboarding throughout your career
- Annual bonus eligibility
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