Nurse Care Manager - Compassionate Care Program

Job Description:

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 Senior Director 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 Senior Director 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.

This role will primarily support patients in the Central Time Zone but will also work with patients in all US time zones as needed.

Primary Functions

• 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 in palliation of symptoms and develop a plan of care collaboratively with the patient’s providers.
• Engage internal resources to identify and respond to social determinants of health such as lack of transportation, stable housing, or food resources.
• Actively participate in huddles, IDT sessions, and patient case conferences as appropriate.
• Interface with Nephrology Partners, Primary Care Physicians, Advanced Practice Providers, Specialists, and various disciplines on the development of case management plans/programs.
• Develop the plan of care with input from the patient/family, as a result of the goals of care discussion(s), and the interdisciplinary team.
• Ensure that accurate records are maintained of the care associated with each patient.
• Communicate and implement the plan of care in all settings, including with community palliative care and hospice providers.
• Coordinating care and access to health services across multiple providers/disciplines (home health, palliative care, hospice, pastoral care and counseling, etc).
• Evaluate the ongoing progress toward appropriate outcomes and care transitions.
• Reassess and revise the plan of care as needed in collaboration with patient/family through ongoing goals of care discussions, and input from the interdisciplinary team, and document appropriately.
• Required to maintain current knowledge and competency of hospice and palliative care nursing.
• Educate internal partners, and external partners in the community, about the ECCP and how to identify and refer patients to the program.
• Commendably represent Evergreen to patients, their families, and the community.

Qualifications

• 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 culture
• You accept that things change quickly in a startup environment and are willing to pivot quickly on priorities
• Current RN License is required, BSN preferred.
• 1+ years of utilization management experience preferred.
• 3+ years of clinical practice in an intensive care unit, or a hospice or palliative care role
• Certified Care Manager experience preferred but not required.
• Experience having goals of care discussions and discussions regarding end-of-life care decisions required
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• You have the ability to work effectively in a primarily remote environment:
• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wired to the house internet (Cable, Fiber, or DSL) and hardwired to the internet device is recommended
• Evergreen will provide Remote or Hybrid Home/Office employees with telephony applications and equipment to meet the business requirements for their position/job
• Team Members must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Compensation

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

Benefits

You will benefit from Evergreen Nephrology’s exceptional total rewards package, which includes: 

• Competitive base pay with bonuses 

• 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 

• 401(k) with match 

• Paid parental leave 

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

Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws. 

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.