Program Manager – Chronic and Complex Care Management, Transitions of Care
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Job Description
Lead care management team at Evergreen Nephrology to deliver patient-centered services for chronic care. Ensuring adherence to care pathways and improving patient outcomes in a remote environment.
Responsibilities:
- Oversee day-to-day operations for the CCPM and TOC care management teams, ensuring efficient workflows, standardized processes, and consistent achievement of program goals.
- Ensure delivery of high-quality longitudinal chronic/complex care management and best-in-class transitions of care, including adherence to clinical pathways, protocols, and documentation standards.
- Continuously evaluate and improve the performance of CCPM and TOC programs and team members, consistent with Evergreen’s performance management philosophy.
- Develop and implement collaborative strategies to improve program performance and patient outcomes (e.g., chronic disease control, complication prevention, and reduced readmissions) while ensuring patient and provider partner satisfaction.
- Support newly hired CCPM/TOC team members through orientation and onboarding; provide ongoing training, coaching, and development for established team members.
- Perform regular call and documentation (chart) audits to support performance management and identify opportunities for continuous improvement.
- Prepare performance reports, dashboards (as applicable), and meeting materials for CCPM and TOC programs for internal and external audiences.
- Oversee TOC workflows that support timely post-discharge outreach, medication reconciliation support, follow-up appointment coordination, and issue escalation to reduce avoidable readmissions.
- Develop and foster relationships with key stakeholders (e.g., IDT members, market leaders, and other program leaders) to drive outcomes through collaboration and cross-program partnership across CCPM and TOC.
- Build and maintain effective communication strategies between Evergreen and market stakeholders to foster strong relationships that support improved patient outcomes, in collaboration with market leaders.
- Be a Culture Champion by cultivating a culture of high performance, transparency, trust, and collaboration.
- Other duties consistent with this role, as assigned.
Requirements:
- Bachelor’s degree in healthcare or nursing (BSN required)
- Active state nursing license in good standing
- 3+ years of longitudinal clinical nursing care management experience required
- 2+ years of experience in a clinical nursing managerial or leadership role
- Experience in longitudinal care management
- Strong business acumen of value-based healthcare operations in disease management and population health programs
- Understanding of Business Continuity and how to build resiliency into business processes/systems
- Ability to develop talent, know when to delegate, innovate and iterate with your team, leveraging their strengths
- Exceptional relationship-building, communication, and change management skills, with the ability to influence effectively and establish trust and credibility quickly with internal and external partners
- Strong leadership presence which inspires others and instills confidence in peers, external partners, board members, and team members
- Execution-focused and hands-on, with the ability to effectively balance strategic priorities and detailed, day-to-day operational work (“in the weeds”).
- Able to motivate staff; influence people and outcomes, you promote team building
- Demonstrated ability to work effectively independently and as part of a team, in collaborative settings
- Commitment to maintaining highest level of confidentiality
- Organizational skills, operational rigor, resilience, and commitment to the business
- 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.
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
- 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
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