Nurse Care Manager
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Job Description
Nurse Care Manager coordinating patient-centered kidney care for Evergreen Nephrology. Managing care plans, transitions, clinical resources, and outcomes remotely during Central Time hours.
Responsibilities:
- Manage the overall care management of an assigned patient panel using clinical expertise, nursing knowledge, and value-based care principles
- Build trusting relationships with patients and families and provide clinical and emotional support throughout their care journey
- Serve as a patient advocate and community liaison, ensuring timely access to resources, support, and adherence to individualized treatment plans
- Conduct comprehensive assessments, including social determinants of health, to identify patient and caregiver needs, goals, and preferences
- Develop and maintain patient-centered care plans based on ongoing assessments and evaluations
- Coordinate post-discharge follow-up, medication reconciliation, referrals, and care plan implementation
- Coordinate interdisciplinary care to improve continuity, reduce fragmentation, and support seamless transitions across care settings
- Monitor care plan effectiveness and modify interventions as needed to achieve desired outcomes
- Follow evidence-based guidelines and established workflows to meet organizational, regulatory, payer, and quality requirements
- Identify cost-effective interventions and resources that improve outcomes and support responsible resource utilization
- Educate patients and caregivers on treatment options, self-management strategies, and available resources
- Participate in clinical huddles, interdisciplinary care conferences, and patient care discussions
- Drive process improvement in care management workflows, patient engagement, transitions of care, and patient experience
- Prepare reports and communications related to program updates, outcomes, and performance
- Collect, analyze, and report data on program performance, patient outcomes, quality measures, and patient/caregiver satisfaction
- Perform other duties consistent with the role, as assigned
Requirements:
- Associate Degree in Nursing
- Current RN license required; compact license preferred
- 3+ years of care management experience
- Chronic and complex care management experience
- 2+ years of Transitions of Care experience preferred
- Utilization management experience preferred
- Certified Case Manager preferred
- Intermediate skills with MS Office Suite of products including Outlook and Teams
- Able to work effectively in a primarily remote environment
- Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps; Cable, Fiber, or DSL connections hardwired to the internet device are recommended
- Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
- Must be able to work 8:30a–5p CT
- Must collaborate with physicians, APPs, IDT members, providers, vendors, and community-based services
Benefits:
- Quarterly 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
- Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
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