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. We help nephrologists focus on the right patients at the right time across the full care spectrum. This role may be filled by a Registered Nurse (RN) or a licensed Physical Therapist (PT) meeting equivalent qualification criteria.

Responsibilities

• 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.

Requirements

• 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 telephonic care management and post-acute care
• Active license in good standing in the state of Illinois
• Experience in Utilization Management and/or Utilization Review
• Experience in specialty care including kidney care or related field
• Excellent communication, problem-solving and organizational skills
• Knowledge of value-based care models and strategies to reduce readmissions
• Experience with team-based care and have excellent collaboration skills
• Excellent working knowledge of community resources
• Strong understanding of skilled nursing facility operations and regulations strongly 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

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 telephonic care management and post-acute care
• Active license in good standing in the state of Illinois
• Experience in Utilization Management and/or Utilization Review
• Experience in specialty care including kidney care or related field
• Excellent communication, problem-solving and organizational skills
• Knowledge of value-based care models and strategies to reduce readmissions
• Experience with team-based care and have excellent collaboration skills
• Excellent working knowledge of community resources
• Strong understanding of skilled nursing facility operations and regulations strongly 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

Pay

The pay range for this role is $90,000 to $103,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.

Schedule

This role may be filled by a Registered Nurse (RN) or a licensed Physical Therapist (PT) meeting equivalent qualification criteria. While this position is fully remote, you must be able to work 8:30am – 5pm in the Central or Eastern time zone.

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
• Paid parental leave
• A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology

Contact

If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at recruiting@evergreennephrology.com.