Case Management Nurse

Who You AreYou are devoted and compassionate, and enjoy being on the front lines of healthcare, changing the lives of your patients. You’re passionate about digging in to get to the root cause of a patient’s conditions, remove social determinants of healthcare, and ensure the highest possible quality of life and best outcomes for those in your care. You believe patients living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You don’t want to sacrifice quality over quantity, and you aim to provide the same level of care and commitment to your team and patients that you would to your own family member. You thrive in innovative and evolving environments with high rates of change. You are driven by process improvements. Does this sound like you? If so, we should talk.Who We AreEvergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care and we are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients.We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.Your RoleAs a Nurse Care Manager with Evergreen Nephrology, you will collaborate with a team of Physicians, Advanced Practice Providers, and interdisciplinary team members to manage an assigned patent panel and address patients’ specialized needs based on their individual conditions. Your job duties will include taking full ownership of patients within your panel, with an additional focus on helping patients with kidney disease navigate the kidney care continuum and manage all their additional chronic conditions. You will perform assessments to identify their needs based on their values, goals, and preferences. From this assessment, you will develop comprehensive care plans for each member. These care plans will be used to coordinate patient care delivery with Evergreen and our JV partner clinicians, network providers, contracted vendors, and community-based services. Primary functions for the Nurse Care Manager include:· Quickly build empathetic relationships with patients and familiesEvaluate and identify patient’s needs based on their respective values, goals, and preferences, then translate these needs into clinical needsInterface with Nephrology Partners, Primary Care Physicians, Advanced Practice Providers, Specialists, and various disciplines on the development of case management plans/programsIn conjunction with the Nephrologist partner/APP, implement care/treatment plan by coordinating access to health services across multiple providers/disciplinesMonitor care and identify cost-effective measures, including recommendations for alternative levels of care and utilization of resourcesEffectively coordinate patient education (including family involvement as appropriate) regarding treatment options, and advocate for access to the preferred treatment optionMonitor and evaluate the effectiveness of the case management plans based on quality and cost drivers and modifies as necessaryCoordinate the interdisciplinary approach to providing continuity of care, including kidney disease progression management, utilization management, kidney care coordination, needed for outside services for patients/familiesAct as a clinical liaison, per their specialty, with outside agencies such as County CCS, non-plan facilities, outside providers, employers and/or workers' compensation carriers, and third-party administratorsPrepare reports, communicate program changes to appropriate staff, and develop protocols in accordance with compliance requirementsCoordinate and advocate for effective transition of care when appropriate/neededEngage internal resources to identify and respond to Social Determinants of Health such as lack of transportation, stable housing, or food resourcesParticipate in the data collection, formulation and implementation, and monitoring of action strategies and outcomes of care or customer serviceEnsure that accurate records are maintained of the care associated with each patientInterpret regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agenciesActively participate in huddles, IDT sessions, and patient case conferencesCommendably represent Evergreen to patients, their families, and the communityHow You Qualify· You reviewed the Who You Are section of this job posting and immediately felt the need to read on. That makes you a match for our innovative cultureYou accept that things change quickly in a startup environment and are willing to pivot quickly on prioritiesCurrent RN License is required, BSN preferred.1+ years of utilization management experience preferred.3+ years of clinical practice in a hospital, clinic, home care, or nursing home setting highlyCase management experience and CCM preferred but not required.Disease management and/or physician office experience How You are SupportedYou will benefit from Evergreen Nephrology’s exceptional total rewards package, including competitive base pay with bonuses, paid time off starting at four weeks for full-time employees, 12 paid holidays per year, reimbursement for continuing medical education, 401k with match, health, dental, and vision insurance.We are proud to offer family-friendly policies that support paid parental leave and flexible work arrangements.We commit to a robust training and development program that starts with onboarding and continues throughout your career with Evergreen NephrologyAs an inclusive and diverse team, you will collaborate with like-minded healthcare professionals who, like you, understand the importance and value of Evergreen Nephrology’s high-quality, value-based care model.