Nurse Care Manager

Who You Are

You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.
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 a Nurse Care Manager with Evergreen Nephrology , you are responsible for managing an assigned patient panel and addressing each patient's specialized needs based on their individual conditions, healthcare needs, goals, wishes, and recent care transitions. You will collaborate with physicians, APPs, and IDT members. Nurse Care Managers support programs including Chronic Complex Care Management, Compassionate Care Management, Post Acute Care, Transitions of Care, and CKD Navigation.

This role includes supporting patients following hospitalization, helping them navigate the kidney care continuum, developing comprehensive care plans, coordinating care with Evergreen clinicians, JV partners, network providers, contracted vendors, and community-based services, and reducing preventable readmissions.

While our Nurse Care Manager positions are fully remote , this specific position will support patients in the Central Time Zone and must be able to work 8:30a - 5p CT.
Role Responsibilities

Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:
- 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 to 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 with physicians, APPs, community providers, vendors, and other clinical disciplines.

- 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 deliver high-quality care that meets organizational, regulatory, payer, and quality requirements.

- Identify cost-effective interventions and resources that improve outcomes and support responsible resource utilization.

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