Nurse Care Manager - Compassionate Care Program
Who You Are
You are devoted, compassionate, and enjoy being on the front lines in 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.
Who We Are
Evergreen 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. 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 Role
As an Evergreen Compassionate Care Nurse Care Manager with Evergreen Nephrology , you will work closely with the Program Manager of the Evergreen Compassionate Care Program (ECCP) to manage the healthcare journey of patients referred to the program based on their unique healthcare needs, goals, and wishes. You will collaborate with a team of Physicians, Advanced Practice Providers, and interdisciplinary team members to manage patients referred to the ECCP by taking full ownership of patients within your panel, focusing on helping patients with kidney disease understand their diagnosis and prognosis as well as services available to them so they are empowered to make healthcare decisions they are comfortable with.
You will perform assessments and advance care planning conversations to identify their needs based on their values, goals, and preferences. You will assess patients for hospice appropriateness and hospice-mindedness. From this assessment, you will either refer patients to the appropriate program within Evergreen for ongoing kidney care management with or without dialysis, and or will coordinate continued care under their nephrologist; or coordinate a transition to hospice care in collaboration with community providers. You will act as a clinical liaison and educator, working closely with the Program Manager of the ECCP, to provide resources and training both internally and externally regarding identifying patients who need advance care planning and goals or care discussions, and/or patients who may be appropriate for hospice care.
While this position is fully remote , you must be able to work 8:30am – 5pm in the Central time zone.
Role Responsibilities
- Quickly build empathetic relationships with patients and families.
- Effectively complete patient education (including family involvement as appropriate) regarding diagnosis, prognosis, treatment options, and advocate for access to the preferred treatment option.
- Evaluate and identify patient’s needs based on their respective values, goals, and preferences by completing advance care planning (ACP) including a Goals Of Care (GOC) discussion and then translate the needs into clinical needs.
- Apply critical thinking skills to the analysis of the data collected.
- Identify opportunities for improvement i